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
Clinical Scenario: A client receiving cycle 1 of chemotherapy
returns to the clinic on day 8 with a temperature of 38.3°C
(100.9°F), chills, and an absolute neutrophil count (ANC) of
500/mm³.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and reassess the temperature in 4
hours.
B. Notify the provider immediately and prepare for blood
cultures and broad-spectrum IV antibiotics.
C. Place the client in a semiprivate room to reduce feelings of
isolation.
D. Administer acetaminophen and wait for the next CBC result.
Correct Answer: B
Detailed Rationale: Fever with severe neutropenia is a medical
emergency. The nurse should treat this as suspected
neutropenic infection/sepsis and escalate care immediately.
Incorrect Option Analysis:
• A: Delays urgent treatment.
• C: Unsafe because exposure risk remains high.
• D: Masks fever and delays diagnosis.
Nursing Process Linkage: Implementation
, NCJMM Competencies: Recognize Cues, Prioritize
Hypotheses, Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration: Risk for infection related to
myelosuppression
Expected Outcome: The client receives cultures and
antibiotics promptly and remains hemodynamically stable.
Key Learning Objective: Recognize and respond to
neutropenic fever as an oncologic emergency.
2. SATA
Clinical Scenario: A client is receiving external beam radiation
to the neck. The skin over the treatment field is red and tender.
Question Stem: Which teaching points should the nurse
include? Select all that apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap.
B. Apply an ice pack to the treatment field twice daily.
C. Wear loose cotton clothing over the area.
D. Use perfumed lotions or deodorants on the field.
E. Protect the site from direct sun exposure.
Correct Answers: A, C, E
, Detailed Rationale: Radiation skin care focuses on preventing
additional irritation and protecting fragile tissue.
Incorrect Option Analysis:
• A: Correct; gentle cleansing reduces trauma.
• B: Incorrect; extreme temperatures can worsen skin injury.
• C: Correct; reduces friction.
• D: Incorrect; perfumes and chemicals irritate irradiated
skin.
• E: Correct; sun can worsen radiation dermatitis.
Nursing Process Linkage: Planning
NCJMM Competencies: Generate Solutions, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Basic Care and Comfort
Nursing Diagnosis Integration: Risk for impaired skin
integrity related to radiation exposure
Expected Outcome: The client protects the radiated skin
and reports reduced irritation.
Key Learning Objective: Select safe self-care measures for
radiation therapy skin reactions.
3. MCQ
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1. MCQ
Clinical Scenario: A client receiving cycle 1 of chemotherapy
returns to the clinic on day 8 with a temperature of 38.3°C
(100.9°F), chills, and an absolute neutrophil count (ANC) of
500/mm³.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and reassess the temperature in 4
hours.
B. Notify the provider immediately and prepare for blood
cultures and broad-spectrum IV antibiotics.
C. Place the client in a semiprivate room to reduce feelings of
isolation.
D. Administer acetaminophen and wait for the next CBC result.
Correct Answer: B
Detailed Rationale: Fever with severe neutropenia is a medical
emergency. The nurse should treat this as suspected
neutropenic infection/sepsis and escalate care immediately.
Incorrect Option Analysis:
• A: Delays urgent treatment.
• C: Unsafe because exposure risk remains high.
• D: Masks fever and delays diagnosis.
Nursing Process Linkage: Implementation
, NCJMM Competencies: Recognize Cues, Prioritize
Hypotheses, Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration: Risk for infection related to
myelosuppression
Expected Outcome: The client receives cultures and
antibiotics promptly and remains hemodynamically stable.
Key Learning Objective: Recognize and respond to
neutropenic fever as an oncologic emergency.
2. SATA
Clinical Scenario: A client is receiving external beam radiation
to the neck. The skin over the treatment field is red and tender.
Question Stem: Which teaching points should the nurse
include? Select all that apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap.
B. Apply an ice pack to the treatment field twice daily.
C. Wear loose cotton clothing over the area.
D. Use perfumed lotions or deodorants on the field.
E. Protect the site from direct sun exposure.
Correct Answers: A, C, E
, Detailed Rationale: Radiation skin care focuses on preventing
additional irritation and protecting fragile tissue.
Incorrect Option Analysis:
• A: Correct; gentle cleansing reduces trauma.
• B: Incorrect; extreme temperatures can worsen skin injury.
• C: Correct; reduces friction.
• D: Incorrect; perfumes and chemicals irritate irradiated
skin.
• E: Correct; sun can worsen radiation dermatitis.
Nursing Process Linkage: Planning
NCJMM Competencies: Generate Solutions, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Basic Care and Comfort
Nursing Diagnosis Integration: Risk for impaired skin
integrity related to radiation exposure
Expected Outcome: The client protects the radiated skin
and reports reduced irritation.
Key Learning Objective: Select safe self-care measures for
radiation therapy skin reactions.
3. MCQ
