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
,Clinical Scenario:
A 62-year-old client with lymphoma is receiving
myelosuppressive chemotherapy. Today, the client’s
temperature is 38.3°C (100.9°F), neutrophil count is 600/mm³,
and the client reports feeling “slightly tired” but otherwise well.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Administer acetaminophen and recheck the temperature in 1
hour
B. Place the client on protective precautions and notify the
provider immediately
C. Encourage oral fluids and rest at home
D. Delay action because fatigue is expected during
chemotherapy
Correct Answer:
B. Place the client on protective precautions and notify the
provider immediately
Detailed Rationale:
Fever in a client with severe neutropenia is a medical
emergency because infection may progress rapidly without
typical inflammatory signs. Immediate protective precautions
and provider notification support rapid workup and treatment.
Early action reduces sepsis risk.
,Incorrect Option Analysis:
• A: Antipyretics may mask fever and delay definitive
treatment.
• C: Home care is unsafe with febrile neutropenia.
• D: Fatigue may be expected, but fever is not benign in
neutropenia.
Nursing Process Linkage:
Assessment / Implementation
NCJMM Competencies:
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Safety and Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppressive chemotherapy, neutropenia,
invasive disease process
Expected Outcome:
The client will receive prompt evaluation and treatment for
possible infection within the same encounter.
, Key Learning Objective:
Recognize febrile neutropenia as an urgent oncology safety
issue.
2) SATA — Cancer Care: Immunotherapy Adverse Effects
Clinical Scenario:
A client receiving an immune checkpoint inhibitor for metastatic
cancer calls the clinic reporting new symptoms.
Question Stem:
Which symptoms should the nurse instruct the client to report
immediately? Select all that apply.
Answer Options:
A. New diarrhea
B. Mild fatigue after treatment
C. Yellowing of the skin
D. Shortness of breath
E. Itchy rash
F. Increased appetite
Correct Answers:
A, C, D, E
Detailed Rationale:
Immune checkpoint inhibitors can cause immune-related
adverse events affecting the bowel, liver, skin, and lungs.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,Clinical Scenario:
A 62-year-old client with lymphoma is receiving
myelosuppressive chemotherapy. Today, the client’s
temperature is 38.3°C (100.9°F), neutrophil count is 600/mm³,
and the client reports feeling “slightly tired” but otherwise well.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Administer acetaminophen and recheck the temperature in 1
hour
B. Place the client on protective precautions and notify the
provider immediately
C. Encourage oral fluids and rest at home
D. Delay action because fatigue is expected during
chemotherapy
Correct Answer:
B. Place the client on protective precautions and notify the
provider immediately
Detailed Rationale:
Fever in a client with severe neutropenia is a medical
emergency because infection may progress rapidly without
typical inflammatory signs. Immediate protective precautions
and provider notification support rapid workup and treatment.
Early action reduces sepsis risk.
,Incorrect Option Analysis:
• A: Antipyretics may mask fever and delay definitive
treatment.
• C: Home care is unsafe with febrile neutropenia.
• D: Fatigue may be expected, but fever is not benign in
neutropenia.
Nursing Process Linkage:
Assessment / Implementation
NCJMM Competencies:
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Safety and Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppressive chemotherapy, neutropenia,
invasive disease process
Expected Outcome:
The client will receive prompt evaluation and treatment for
possible infection within the same encounter.
, Key Learning Objective:
Recognize febrile neutropenia as an urgent oncology safety
issue.
2) SATA — Cancer Care: Immunotherapy Adverse Effects
Clinical Scenario:
A client receiving an immune checkpoint inhibitor for metastatic
cancer calls the clinic reporting new symptoms.
Question Stem:
Which symptoms should the nurse instruct the client to report
immediately? Select all that apply.
Answer Options:
A. New diarrhea
B. Mild fatigue after treatment
C. Yellowing of the skin
D. Shortness of breath
E. Itchy rash
F. Increased appetite
Correct Answers:
A, C, D, E
Detailed Rationale:
Immune checkpoint inhibitors can cause immune-related
adverse events affecting the bowel, liver, skin, and lungs.
