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: Chemotherapy Safety
Clinical Scenario:
A 52-year-old client with breast cancer is receiving
chemotherapy and reports a sore throat, chills, and feeling
unusually weak 10 days after treatment.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and rest
B. Obtain a complete blood count and notify the provider
C. Administer the next chemotherapy dose on schedule
D. Reassure the client that these symptoms are expected
Correct Answer:
B. Obtain a complete blood count and notify the provider
Detailed Rationale:
These findings suggest possible neutropenia and infection,
which are urgent chemotherapy complications. A CBC helps
confirm neutropenia, and the provider must be notified
promptly for possible protective precautions and treatment.
Incorrect Option Analysis:
• A: Fluids and rest are helpful but do not address possible
life-threatening infection.
, • C: Chemotherapy should not continue without evaluation
of possible infection.
• D: These symptoms are not expected and require
immediate assessment.
Common misconception: assuming fatigue and sore throat
are routine after chemotherapy.
Safety issue: delayed recognition of neutropenic sepsis.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Myelosuppression, chemotherapy
Expected Outcome:
The client will be evaluated promptly for infection and
neutropenia, and treatment will begin within an appropriate
timeframe.
, Key Learning Objective:
Recognize urgent chemotherapy complications and prioritize
infection control.
2. SATA — Cancer Care: Neutropenic Precautions
Clinical Scenario:
A client receiving chemotherapy has an absolute neutrophil
count of 450/mm³.
Question Stem:
Which nursing actions should be included in the plan of care?
Select all that apply.
Answer Options:
A. Place the client in a private room
B. Perform hand hygiene before all contact
C. Encourage fresh flowers in the room
D. Monitor temperature every 4 hours
E. Instruct the client to avoid raw fruits and vegetables
F. Use a rectal thermometer for accurate readings
Correct Answers:
A, B, D, E
Detailed Rationale:
Neutropenia increases infection risk. Private room, strict hand
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1. MCQ — Cancer Care: Chemotherapy Safety
Clinical Scenario:
A 52-year-old client with breast cancer is receiving
chemotherapy and reports a sore throat, chills, and feeling
unusually weak 10 days after treatment.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and rest
B. Obtain a complete blood count and notify the provider
C. Administer the next chemotherapy dose on schedule
D. Reassure the client that these symptoms are expected
Correct Answer:
B. Obtain a complete blood count and notify the provider
Detailed Rationale:
These findings suggest possible neutropenia and infection,
which are urgent chemotherapy complications. A CBC helps
confirm neutropenia, and the provider must be notified
promptly for possible protective precautions and treatment.
Incorrect Option Analysis:
• A: Fluids and rest are helpful but do not address possible
life-threatening infection.
, • C: Chemotherapy should not continue without evaluation
of possible infection.
• D: These symptoms are not expected and require
immediate assessment.
Common misconception: assuming fatigue and sore throat
are routine after chemotherapy.
Safety issue: delayed recognition of neutropenic sepsis.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Myelosuppression, chemotherapy
Expected Outcome:
The client will be evaluated promptly for infection and
neutropenia, and treatment will begin within an appropriate
timeframe.
, Key Learning Objective:
Recognize urgent chemotherapy complications and prioritize
infection control.
2. SATA — Cancer Care: Neutropenic Precautions
Clinical Scenario:
A client receiving chemotherapy has an absolute neutrophil
count of 450/mm³.
Question Stem:
Which nursing actions should be included in the plan of care?
Select all that apply.
Answer Options:
A. Place the client in a private room
B. Perform hand hygiene before all contact
C. Encourage fresh flowers in the room
D. Monitor temperature every 4 hours
E. Instruct the client to avoid raw fruits and vegetables
F. Use a rectal thermometer for accurate readings
Correct Answers:
A, B, D, E
Detailed Rationale:
Neutropenia increases infection risk. Private room, strict hand
