The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action?

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The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. (Option B) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm³ (150 x 10⁹/L). ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells. Petechiae are an expected finding. (Option C) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic demands (oxygen supply) associated with activity. This is an expected finding. (Option D) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding. Educational objective: Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life-threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention.

The Nurse Assesses 4 Clients