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: Febrile Neutropenia
Clinical Scenario:
A 58-year-old patient receiving combination chemotherapy for
colorectal cancer calls the nurse from home. The patient
reports a temperature of 38.4°C (101.1°F), chills, and “feeling
weak.” The most recent CBC showed an absolute neutrophil
count of 420/mm³.
Stem:
What is the nurse’s priority instruction?
Answer Options:
A. Take acetaminophen and recheck the temperature in 4
hours.
B. Go to the emergency department immediately for urgent
evaluation.
C. Increase fluid intake and rest at home.
D. Hold the next chemotherapy dose until the next clinic visit.
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, which is a medical
emergency because even a mild infection can progress rapidly
,to sepsis. The nurse should direct the patient to immediate
urgent evaluation for cultures, IV antibiotics, and monitoring.
Incorrect Option Analysis:
• A: Incorrect. Acetaminophen may mask fever and delay
treatment. Common misconception: treating fever first
instead of urgent evaluation.
• C: Incorrect. Rest and fluids do not address the infection
risk. Safety concern: delayed sepsis management.
• D: Incorrect. Holding chemotherapy is appropriate later,
but it is not the first priority.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection / actual
infection
• Risk Factors: neutropenia, chemotherapy-induced bone
marrow suppression
Expected Outcome: The patient receives immediate
evaluation and antibiotics without delay.
, Key Learning Objective: Prioritize emergency care for
chemotherapy-related neutropenic fever.
2) SATA — Chemotherapy Patient Teaching
Clinical Scenario:
A patient who started chemotherapy 1 week ago says, “I want
to know which symptoms mean I should call the oncology clinic
right away.”
Stem:
Which findings should the nurse instruct the patient to report
immediately? Select all that apply.
Answer Options:
A. Temperature of 38.0°C (100.4°F)
B. Mild hair thinning
C. Black, tarry stools
D. New numbness and tingling in the fingers
E. Mild fatigue after treatment
F. Mouth sores that make swallowing painful
Correct Answers:
A, C, D, F
Detailed Rationale:
Fever can indicate infection in an immunocompromised patient.
Black, tarry stools may signal GI bleeding from
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care: Febrile Neutropenia
Clinical Scenario:
A 58-year-old patient receiving combination chemotherapy for
colorectal cancer calls the nurse from home. The patient
reports a temperature of 38.4°C (101.1°F), chills, and “feeling
weak.” The most recent CBC showed an absolute neutrophil
count of 420/mm³.
Stem:
What is the nurse’s priority instruction?
Answer Options:
A. Take acetaminophen and recheck the temperature in 4
hours.
B. Go to the emergency department immediately for urgent
evaluation.
C. Increase fluid intake and rest at home.
D. Hold the next chemotherapy dose until the next clinic visit.
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, which is a medical
emergency because even a mild infection can progress rapidly
,to sepsis. The nurse should direct the patient to immediate
urgent evaluation for cultures, IV antibiotics, and monitoring.
Incorrect Option Analysis:
• A: Incorrect. Acetaminophen may mask fever and delay
treatment. Common misconception: treating fever first
instead of urgent evaluation.
• C: Incorrect. Rest and fluids do not address the infection
risk. Safety concern: delayed sepsis management.
• D: Incorrect. Holding chemotherapy is appropriate later,
but it is not the first priority.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection / actual
infection
• Risk Factors: neutropenia, chemotherapy-induced bone
marrow suppression
Expected Outcome: The patient receives immediate
evaluation and antibiotics without delay.
, Key Learning Objective: Prioritize emergency care for
chemotherapy-related neutropenic fever.
2) SATA — Chemotherapy Patient Teaching
Clinical Scenario:
A patient who started chemotherapy 1 week ago says, “I want
to know which symptoms mean I should call the oncology clinic
right away.”
Stem:
Which findings should the nurse instruct the patient to report
immediately? Select all that apply.
Answer Options:
A. Temperature of 38.0°C (100.4°F)
B. Mild hair thinning
C. Black, tarry stools
D. New numbness and tingling in the fingers
E. Mild fatigue after treatment
F. Mouth sores that make swallowing painful
Correct Answers:
A, C, D, F
Detailed Rationale:
Fever can indicate infection in an immunocompromised patient.
Black, tarry stools may signal GI bleeding from
