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
Clinical Scenario:
A 56-year-old client receiving chemotherapy for colon cancer
reports a temperature of 38.6°C (101.5°F), chills, and mild
fatigue. The nurse notes the client’s absolute neutrophil count
is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and recheck the temperature in 1 hour
B. Place the client on neutropenic precautions and notify the
provider immediately
C. Administer acetaminophen and document the findings
D. Teach the client to avoid raw fruits and vegetables at home
Correct Answer:
B. Place the client on neutropenic precautions and notify the
provider immediately
Detailed Rationale:
This client has febrile neutropenia, a medical emergency in
oncology. A temperature above 38°C in a client with severe
neutropenia may indicate serious infection even before other
,signs appear. Immediate action is required to reduce exposure
and ensure prompt treatment.
Incorrect Option Analysis:
• A: Delays care; febrile neutropenia requires urgent
escalation.
• C: Acetaminophen may mask fever and delay recognition
of infection.
• D: Dietary teaching is appropriate later, but not the priority
in an acute infection risk.
Nursing Process Linkage:
Assessment → Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; 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: Chemotherapy-induced neutropenia, invasive
cancer treatment
Expected Outcome:
The client remains hemodynamically stable and receives
infection treatment within the appropriate time frame.
Key Learning Objective:
Recognize and prioritize febrile neutropenia as an oncologic
emergency.
2) SATA
Clinical Scenario:
A client starting outpatient chemotherapy asks the nurse what
side effects should be reported right away.
Question Stem:
Which findings should the nurse instruct the client to report
immediately? Select all that apply.
Answer Options:
A. Fever of 38°C (100.4°F)
B. Mouth sores that interfere with eating
C. Mild fatigue after treatment
D. Black, tarry stools
E. New shortness of breath
F. Temporary hair thinning
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
Clinical Scenario:
A 56-year-old client receiving chemotherapy for colon cancer
reports a temperature of 38.6°C (101.5°F), chills, and mild
fatigue. The nurse notes the client’s absolute neutrophil count
is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and recheck the temperature in 1 hour
B. Place the client on neutropenic precautions and notify the
provider immediately
C. Administer acetaminophen and document the findings
D. Teach the client to avoid raw fruits and vegetables at home
Correct Answer:
B. Place the client on neutropenic precautions and notify the
provider immediately
Detailed Rationale:
This client has febrile neutropenia, a medical emergency in
oncology. A temperature above 38°C in a client with severe
neutropenia may indicate serious infection even before other
,signs appear. Immediate action is required to reduce exposure
and ensure prompt treatment.
Incorrect Option Analysis:
• A: Delays care; febrile neutropenia requires urgent
escalation.
• C: Acetaminophen may mask fever and delay recognition
of infection.
• D: Dietary teaching is appropriate later, but not the priority
in an acute infection risk.
Nursing Process Linkage:
Assessment → Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; 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: Chemotherapy-induced neutropenia, invasive
cancer treatment
Expected Outcome:
The client remains hemodynamically stable and receives
infection treatment within the appropriate time frame.
Key Learning Objective:
Recognize and prioritize febrile neutropenia as an oncologic
emergency.
2) SATA
Clinical Scenario:
A client starting outpatient chemotherapy asks the nurse what
side effects should be reported right away.
Question Stem:
Which findings should the nurse instruct the client to report
immediately? Select all that apply.
Answer Options:
A. Fever of 38°C (100.4°F)
B. Mouth sores that interfere with eating
C. Mild fatigue after treatment
D. Black, tarry stools
E. New shortness of breath
F. Temporary hair thinning
