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: Neutropenic Fever Priority
Clinical Scenario:
A 62-year-old patient with colon cancer finished chemotherapy
8 days ago. The patient reports chills and weakness. Vital signs
show temperature 38.4°C (101.1°F), HR 112/min, BP 96/60 mm
Hg, and ANC is 600/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and encourage oral fluids
B. Activate the facility’s neutropenic fever protocol and notify
the provider immediately
C. Place the patient in a shared room to reduce isolation stress
D. Encourage fresh fruits and vegetables to improve intake
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency in
oncology. The nurse must treat this as potential sepsis and
activate the neutropenic fever protocol immediately. That
typically includes urgent provider notification, cultures, and
prompt antibiotics per protocol.
,Incorrect Option Analysis:
• A is incorrect because antipyretics alone do not address
the risk of rapid systemic infection.
• C is incorrect because the patient should be protected
from infectious exposure.
• D is incorrect because raw produce may carry microbes
and is avoided with neutropenia.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Reduction of Risk Potential
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, recent chemotherapy, fever
Expected Outcome:
Patient will receive urgent sepsis-prevention management
with no progression to shock.
Key Learning Objective:
Recognize febrile neutropenia as an immediate safety
threat and initiate oncology emergency care.
, 2) SATA — Radiation Therapy Skin Care
Clinical Scenario:
A patient receiving external beam radiation to the chest asks
how to care for the skin in the treatment area.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap
B. Pat the area dry instead of rubbing
C. Apply perfume or deodorant directly over the treated skin
D. Wear loose, soft clothing over the treatment field
E. Protect the area from sun exposure
F. Use adhesive tape on the treatment site if dressing is needed
Correct Answers:
A, B, D, E
Detailed Rationale:
Radiation can inflame and damage skin. Gentle cleansing,
patting dry, loose clothing, and sun protection reduce friction
and irritation. These measures support skin integrity and
comfort.
Incorrect Option Analysis:
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care: Neutropenic Fever Priority
Clinical Scenario:
A 62-year-old patient with colon cancer finished chemotherapy
8 days ago. The patient reports chills and weakness. Vital signs
show temperature 38.4°C (101.1°F), HR 112/min, BP 96/60 mm
Hg, and ANC is 600/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and encourage oral fluids
B. Activate the facility’s neutropenic fever protocol and notify
the provider immediately
C. Place the patient in a shared room to reduce isolation stress
D. Encourage fresh fruits and vegetables to improve intake
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency in
oncology. The nurse must treat this as potential sepsis and
activate the neutropenic fever protocol immediately. That
typically includes urgent provider notification, cultures, and
prompt antibiotics per protocol.
,Incorrect Option Analysis:
• A is incorrect because antipyretics alone do not address
the risk of rapid systemic infection.
• C is incorrect because the patient should be protected
from infectious exposure.
• D is incorrect because raw produce may carry microbes
and is avoided with neutropenia.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Reduction of Risk Potential
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, recent chemotherapy, fever
Expected Outcome:
Patient will receive urgent sepsis-prevention management
with no progression to shock.
Key Learning Objective:
Recognize febrile neutropenia as an immediate safety
threat and initiate oncology emergency care.
, 2) SATA — Radiation Therapy Skin Care
Clinical Scenario:
A patient receiving external beam radiation to the chest asks
how to care for the skin in the treatment area.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap
B. Pat the area dry instead of rubbing
C. Apply perfume or deodorant directly over the treated skin
D. Wear loose, soft clothing over the treatment field
E. Protect the area from sun exposure
F. Use adhesive tape on the treatment site if dressing is needed
Correct Answers:
A, B, D, E
Detailed Rationale:
Radiation can inflame and damage skin. Gentle cleansing,
patting dry, loose clothing, and sun protection reduce friction
and irritation. These measures support skin integrity and
comfort.
Incorrect Option Analysis:
