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 patient is 9 days post–chemotherapy for lymphoma and
reports fever, chills, and a sore throat. The temperature is
38.4°C (101.1°F) and the absolute neutrophil count is 500/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 2 hours
B. Initiate neutropenic precautions and notify the oncology
provider immediately
C. Teach the patient to use acetaminophen at home and rest
D. Place the patient on bed rest and delay further assessment
Correct answer:
B
Detailed rationale:
Fever with severe neutropenia is a medical emergency because
the patient may develop rapid sepsis. The nurse should
immediately reduce infection exposure and notify the provider
for cultures and prompt antibiotic therapy. This is a classic
priority/safety intervention.
Incorrect option analysis:
, • A: Delays urgent treatment. Hydration is helpful, but not
first.
• C: Masks the fever and delays escalation.
• D: Bed rest alone does not address the infection risk.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues; Analyze Cues; Prioritize Hypotheses; Take
Action
Difficulty level:
Difficult
Bloom’s level:
Analyze
NCLEX client needs category:
Physiological Adaptation
Nursing diagnosis integration:
Priority diagnosis: Risk for infection
Risk factors: Myelosuppression, neutropenia, recent
chemotherapy
Expected outcome:
The patient remains afebrile, receives timely sepsis evaluation,
and shows no signs of worsening infection.
, Key learning objective:
Prioritize care for febrile neutropenia.
2) SATA
Clinical scenario:
A patient receiving chemotherapy is being discharged home
after the first cycle.
Question stem:
Which instructions should the nurse include to reduce infection
risk? Select all that apply.
Answer options:
A. Perform hand hygiene frequently
B. Check the temperature daily and report fever promptly
C. Avoid crowds and sick contacts
D. Eat raw sushi to improve protein intake
E. Use a rectal suppository for constipation if needed
F. Wash fresh fruits and vegetables carefully or follow the
neutropenic diet guidance given by the oncology team
Correct answers:
A, B, C, F
Detailed rationale:
These actions reduce exposure to pathogens and support early
recognition of infection. Dietary instructions depend on
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 patient is 9 days post–chemotherapy for lymphoma and
reports fever, chills, and a sore throat. The temperature is
38.4°C (101.1°F) and the absolute neutrophil count is 500/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 2 hours
B. Initiate neutropenic precautions and notify the oncology
provider immediately
C. Teach the patient to use acetaminophen at home and rest
D. Place the patient on bed rest and delay further assessment
Correct answer:
B
Detailed rationale:
Fever with severe neutropenia is a medical emergency because
the patient may develop rapid sepsis. The nurse should
immediately reduce infection exposure and notify the provider
for cultures and prompt antibiotic therapy. This is a classic
priority/safety intervention.
Incorrect option analysis:
, • A: Delays urgent treatment. Hydration is helpful, but not
first.
• C: Masks the fever and delays escalation.
• D: Bed rest alone does not address the infection risk.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues; Analyze Cues; Prioritize Hypotheses; Take
Action
Difficulty level:
Difficult
Bloom’s level:
Analyze
NCLEX client needs category:
Physiological Adaptation
Nursing diagnosis integration:
Priority diagnosis: Risk for infection
Risk factors: Myelosuppression, neutropenia, recent
chemotherapy
Expected outcome:
The patient remains afebrile, receives timely sepsis evaluation,
and shows no signs of worsening infection.
, Key learning objective:
Prioritize care for febrile neutropenia.
2) SATA
Clinical scenario:
A patient receiving chemotherapy is being discharged home
after the first cycle.
Question stem:
Which instructions should the nurse include to reduce infection
risk? Select all that apply.
Answer options:
A. Perform hand hygiene frequently
B. Check the temperature daily and report fever promptly
C. Avoid crowds and sick contacts
D. Eat raw sushi to improve protein intake
E. Use a rectal suppository for constipation if needed
F. Wash fresh fruits and vegetables carefully or follow the
neutropenic diet guidance given by the oncology team
Correct answers:
A, B, C, F
Detailed rationale:
These actions reduce exposure to pathogens and support early
recognition of infection. Dietary instructions depend on
