Which client’s laboratory value requires immediate intervention by a nurse?
Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.