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
Scenario: A patient receiving the second cycle of chemotherapy
reports chills and a sore throat. The temperature is 38.5°C
(101.3°F), and the absolute neutrophil count is 600/mm³.
Stem: What is the nurse’s priority action?
Options:
A. Give acetaminophen and encourage oral fluids
B. Place the patient on protective precautions and notify the
oncology provider immediately
C. Encourage the patient to eat fresh fruit and vegetables
D. Obtain a throat culture and wait for results before acting
Correct answer: B
Rationale: Fever with neutropenia is a medical emergency
because the patient may not mount a normal inflammatory
response. Immediate protective precautions and rapid
escalation reduce infection risk and support timely treatment.
Incorrect options: A masks a potentially serious infection; C
increases exposure to pathogens from uncooked produce; D
delays urgent intervention.
Nursing process linkage: Implementation
NCJMM: Recognize Cues → Prioritize Hypotheses → Take Action
Difficulty: Moderate
,Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Priority diagnosis: Risk for
infection r/t myelosuppression
Expected outcome: Temperature remains < 38°C, and no signs
of sepsis develop during the shift.
Key learning objective: Identify urgent nursing actions for
febrile neutropenia.
2) SATA — Cancer Care
Scenario: A patient is receiving external beam radiation to the
chest wall and has erythema and mild itching over the
treatment field.
Stem: Which teaching points should the nurse include? Select
all that apply.
Options:
A. Clean the area with mild soap and lukewarm water
B. Apply a heating pad to soothe the skin
C. Wear loose, soft cotton clothing
D. Scrub the treatment area to remove skin markings
E. Protect the site from direct sunlight
Correct answers: A, C, E
, Rationale: Radiation skin care focuses on minimizing friction,
heat, and trauma while protecting the irradiated area from
further irritation.
Incorrect options: B can worsen tissue injury; D can damage
fragile skin; both increase the risk of dermatitis and breakdown.
Nursing process linkage: Implementation
NCJMM: Generate Solutions → Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Risk diagnosis: Risk for impaired
skin integrity r/t radiation therapy
Expected outcome: The skin remains intact, with no
progression to moist desquamation.
Key learning objective: Teach evidence-informed skin
protection measures during radiation therapy.
3) MCQ — Cancer Care
Scenario: A patient receiving immune checkpoint inhibitor
therapy reports new-onset watery diarrhea and cramping
abdominal pain.
Stem: Which finding is most concerning and should be reported
immediately?
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care
Scenario: A patient receiving the second cycle of chemotherapy
reports chills and a sore throat. The temperature is 38.5°C
(101.3°F), and the absolute neutrophil count is 600/mm³.
Stem: What is the nurse’s priority action?
Options:
A. Give acetaminophen and encourage oral fluids
B. Place the patient on protective precautions and notify the
oncology provider immediately
C. Encourage the patient to eat fresh fruit and vegetables
D. Obtain a throat culture and wait for results before acting
Correct answer: B
Rationale: Fever with neutropenia is a medical emergency
because the patient may not mount a normal inflammatory
response. Immediate protective precautions and rapid
escalation reduce infection risk and support timely treatment.
Incorrect options: A masks a potentially serious infection; C
increases exposure to pathogens from uncooked produce; D
delays urgent intervention.
Nursing process linkage: Implementation
NCJMM: Recognize Cues → Prioritize Hypotheses → Take Action
Difficulty: Moderate
,Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Priority diagnosis: Risk for
infection r/t myelosuppression
Expected outcome: Temperature remains < 38°C, and no signs
of sepsis develop during the shift.
Key learning objective: Identify urgent nursing actions for
febrile neutropenia.
2) SATA — Cancer Care
Scenario: A patient is receiving external beam radiation to the
chest wall and has erythema and mild itching over the
treatment field.
Stem: Which teaching points should the nurse include? Select
all that apply.
Options:
A. Clean the area with mild soap and lukewarm water
B. Apply a heating pad to soothe the skin
C. Wear loose, soft cotton clothing
D. Scrub the treatment area to remove skin markings
E. Protect the site from direct sunlight
Correct answers: A, C, E
, Rationale: Radiation skin care focuses on minimizing friction,
heat, and trauma while protecting the irradiated area from
further irritation.
Incorrect options: B can worsen tissue injury; D can damage
fragile skin; both increase the risk of dermatitis and breakdown.
Nursing process linkage: Implementation
NCJMM: Generate Solutions → Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Risk diagnosis: Risk for impaired
skin integrity r/t radiation therapy
Expected outcome: The skin remains intact, with no
progression to moist desquamation.
Key learning objective: Teach evidence-informed skin
protection measures during radiation therapy.
3) MCQ — Cancer Care
Scenario: A patient receiving immune checkpoint inhibitor
therapy reports new-onset watery diarrhea and cramping
abdominal pain.
Stem: Which finding is most concerning and should be reported
immediately?
