All-in-One Nursing Care Planning
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1. MCQ — Cancer Care
Clinical Scenario:
A client receiving the first cycle of chemotherapy for lymphoma
calls the clinic reporting a temperature of 38.4°C (101.1°F), sore
throat, and chills. The client’s absolute neutrophil count is
900/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Advise the client to take acetaminophen and rest at home
B. Instruct the client to come to the clinic for evaluation
immediately
C. Tell the client to avoid all visitors for the next 24 hours
D. Schedule the client for a repeat CBC in 3 days
Correct Answer:
B
Detailed Rationale:
This client has possible febrile neutropenia, an oncology
emergency. The nurse should direct the client for immediate
evaluation because infection can progress rapidly when
neutrophils are low. Rapid assessment and treatment reduce
risk for sepsis and death.
Incorrect Option Analysis:
, • A: Incorrect. Fever in neutropenia is not managed at home
first.
• C: Incorrect. Visitor restriction alone does not address the
urgent fever.
• D: Incorrect. Waiting 3 days is unsafe.
Nursing Process Linkage: Assessment / Implementation
NCJMM: Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation / Safety and
Infection Control
Nursing Diagnosis Integration:
• Priority Diagnosis: Risk for infection
• Risk Factors: Myelosuppression from chemotherapy,
neutropenia
Expected Outcome: Client is evaluated and treatment for
neutropenic fever begins within the appropriate time
frame.
Key Learning Objective: Identify a life-threatening cancer
complication and initiate prompt care.
2. SATA — Cancer Care
, Clinical Scenario:
A client receiving head and neck radiation reports painful
mouth sores, decreased appetite, and difficulty swallowing.
Question Stem:
Which nursing instructions are appropriate? Select all that
apply.
Answer Options:
A. Use a soft-bristled toothbrush
B. Rinse the mouth with saline or sodium bicarbonate solution
C. Choose bland, soft foods at room temperature
D. Use alcohol-based mouthwash to reduce bacteria
E. Report worsening pain or inability to swallow
F. Brush aggressively after meals to remove plaque
Correct Answers:
A, B, C, E
Detailed Rationale:
Radiation and chemotherapy can cause mucositis, which
increases pain, reduces intake, and raises infection risk. Gentle
oral care, bland foods, and prompt reporting of worsening
symptoms support healing, hydration, and nutrition.
Incorrect Option Analysis:
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1. MCQ — Cancer Care
Clinical Scenario:
A client receiving the first cycle of chemotherapy for lymphoma
calls the clinic reporting a temperature of 38.4°C (101.1°F), sore
throat, and chills. The client’s absolute neutrophil count is
900/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Advise the client to take acetaminophen and rest at home
B. Instruct the client to come to the clinic for evaluation
immediately
C. Tell the client to avoid all visitors for the next 24 hours
D. Schedule the client for a repeat CBC in 3 days
Correct Answer:
B
Detailed Rationale:
This client has possible febrile neutropenia, an oncology
emergency. The nurse should direct the client for immediate
evaluation because infection can progress rapidly when
neutrophils are low. Rapid assessment and treatment reduce
risk for sepsis and death.
Incorrect Option Analysis:
, • A: Incorrect. Fever in neutropenia is not managed at home
first.
• C: Incorrect. Visitor restriction alone does not address the
urgent fever.
• D: Incorrect. Waiting 3 days is unsafe.
Nursing Process Linkage: Assessment / Implementation
NCJMM: Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation / Safety and
Infection Control
Nursing Diagnosis Integration:
• Priority Diagnosis: Risk for infection
• Risk Factors: Myelosuppression from chemotherapy,
neutropenia
Expected Outcome: Client is evaluated and treatment for
neutropenic fever begins within the appropriate time
frame.
Key Learning Objective: Identify a life-threatening cancer
complication and initiate prompt care.
2. SATA — Cancer Care
, Clinical Scenario:
A client receiving head and neck radiation reports painful
mouth sores, decreased appetite, and difficulty swallowing.
Question Stem:
Which nursing instructions are appropriate? Select all that
apply.
Answer Options:
A. Use a soft-bristled toothbrush
B. Rinse the mouth with saline or sodium bicarbonate solution
C. Choose bland, soft foods at room temperature
D. Use alcohol-based mouthwash to reduce bacteria
E. Report worsening pain or inability to swallow
F. Brush aggressively after meals to remove plaque
Correct Answers:
A, B, C, E
Detailed Rationale:
Radiation and chemotherapy can cause mucositis, which
increases pain, reduces intake, and raises infection risk. Gentle
oral care, bland foods, and prompt reporting of worsening
symptoms support healing, hydration, and nutrition.
Incorrect Option Analysis:
