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 Extravasation
Clinical scenario:
A client receiving IV chemotherapy reports burning and
tightness at the IV site. The nurse notes redness and swelling
around the peripheral catheter.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Flush the IV with normal saline to prevent clotting
B. Stop the infusion and leave the catheter in place
C. Apply firm pressure to the site for 10 minutes
D. Elevate the extremity and continue the infusion slowly
Correct answer:
B. Stop the infusion and leave the catheter in place
Detailed rationale:
This is a likely extravasation, which can cause tissue injury. The
first action is to stop the infusion immediately and leave the
catheter in place so an antidote can be administered if
prescribed and residual drug can be aspirated. This protects the
client from further tissue damage.
Incorrect option analysis:
,A is incorrect because flushing can spread the vesicant and
worsen injury.
C is incorrect because pressure may increase tissue damage.
D is incorrect because continuing the infusion increases harm.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX Client Needs: Safety and Infection Control;
Pharmacological and Parenteral Therapies
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for injury related to vesicant
extravasation
Related factors: Vesicant chemotherapy infusion, peripheral IV
access
Defining characteristics: Burning, swelling, redness, tightness at
site
Expected outcome:
The infusion is stopped promptly and tissue injury is minimized.
, Key learning objective:
Prioritize immediate actions for chemotherapy-related infusion
complications.
2) SATA — Cancer Care: Neutropenic Precautions
Clinical scenario:
A client completed chemotherapy 5 days ago and has an
absolute neutrophil count (ANC) of 450/mm³.
Question stem:
Which interventions should the nurse include in the plan of
care? Select all that apply.
Answer options:
A. Restrict fresh flowers and potted plants
B. Encourage meticulous hand hygiene
C. Obtain a rectal temperature if fever is suspected
D. Avoid raw fruits and undercooked foods
E. Place the client in a private room if possible
F. Encourage visitors with respiratory symptoms to wear a mask
and enter anyway
Correct answers:
A, B, D, E
Detailed rationale:
The client is severely neutropenic and at high risk for infection.
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 Extravasation
Clinical scenario:
A client receiving IV chemotherapy reports burning and
tightness at the IV site. The nurse notes redness and swelling
around the peripheral catheter.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Flush the IV with normal saline to prevent clotting
B. Stop the infusion and leave the catheter in place
C. Apply firm pressure to the site for 10 minutes
D. Elevate the extremity and continue the infusion slowly
Correct answer:
B. Stop the infusion and leave the catheter in place
Detailed rationale:
This is a likely extravasation, which can cause tissue injury. The
first action is to stop the infusion immediately and leave the
catheter in place so an antidote can be administered if
prescribed and residual drug can be aspirated. This protects the
client from further tissue damage.
Incorrect option analysis:
,A is incorrect because flushing can spread the vesicant and
worsen injury.
C is incorrect because pressure may increase tissue damage.
D is incorrect because continuing the infusion increases harm.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX Client Needs: Safety and Infection Control;
Pharmacological and Parenteral Therapies
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for injury related to vesicant
extravasation
Related factors: Vesicant chemotherapy infusion, peripheral IV
access
Defining characteristics: Burning, swelling, redness, tightness at
site
Expected outcome:
The infusion is stopped promptly and tissue injury is minimized.
, Key learning objective:
Prioritize immediate actions for chemotherapy-related infusion
complications.
2) SATA — Cancer Care: Neutropenic Precautions
Clinical scenario:
A client completed chemotherapy 5 days ago and has an
absolute neutrophil count (ANC) of 450/mm³.
Question stem:
Which interventions should the nurse include in the plan of
care? Select all that apply.
Answer options:
A. Restrict fresh flowers and potted plants
B. Encourage meticulous hand hygiene
C. Obtain a rectal temperature if fever is suspected
D. Avoid raw fruits and undercooked foods
E. Place the client in a private room if possible
F. Encourage visitors with respiratory symptoms to wear a mask
and enter anyway
Correct answers:
A, B, D, E
Detailed rationale:
The client is severely neutropenic and at high risk for infection.
