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
Clinical Scenario:
A patient with acute myeloid leukemia completed
chemotherapy 8 days ago and now reports chills, sore throat,
and profound fatigue. The temperature is 38.4°C (101.1°F), and
the absolute neutrophil count is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and reassess in 2 hours
B. Place the patient on protective precautions and notify the
provider immediately
C. Administer acetaminophen and document the response
D. Teach the patient to increase dietary fiber and protein
Correct Answer:
B
Detailed Rationale:
Fever in a neutropenic patient is a medical emergency because
infection can become rapidly life-threatening. The nurse should
initiate protective precautions and notify the provider
immediately so diagnostic cultures and broad-spectrum
antibiotics can be started quickly.
,Incorrect Option Analysis:
• A: Delays treatment; infection must not be observed
without escalation.
• C: Acetaminophen may mask fever and delay diagnosis.
• D: Nutrition support is helpful, but not the priority.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation / Safety and
Infection Control
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, recent chemotherapy
Expected Outcome: Patient remains free from sepsis, and
antimicrobial treatment is initiated promptly.
Key Learning Objective: Recognize neutropenic fever as an
urgent oncology complication requiring immediate action.
2) SATA — Cancer Care
, Clinical Scenario:
A patient receiving outpatient chemotherapy asks how to
reduce complications at home.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Report a temperature of 38°C (100.4°F) or higher
immediately
B. Use a soft toothbrush and electric razor
C. Eat raw, unwashed fruits and vegetables to increase vitamins
D. Take prescribed antiemetics before nausea becomes severe
E. Wash hands frequently and avoid exposure to sick contacts
Correct Answers:
A, B, D, E
Detailed Rationale:
These interventions reduce the risk of infection, bleeding, and
uncontrolled nausea. Early reporting of fever is critical because
immunosuppressed patients may deteriorate quickly.
Incorrect Option Analysis:
• C: Unwashed produce increases infection risk during
immunosuppression.
• A: Correct; prevents delay in care.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care
Clinical Scenario:
A patient with acute myeloid leukemia completed
chemotherapy 8 days ago and now reports chills, sore throat,
and profound fatigue. The temperature is 38.4°C (101.1°F), and
the absolute neutrophil count is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and reassess in 2 hours
B. Place the patient on protective precautions and notify the
provider immediately
C. Administer acetaminophen and document the response
D. Teach the patient to increase dietary fiber and protein
Correct Answer:
B
Detailed Rationale:
Fever in a neutropenic patient is a medical emergency because
infection can become rapidly life-threatening. The nurse should
initiate protective precautions and notify the provider
immediately so diagnostic cultures and broad-spectrum
antibiotics can be started quickly.
,Incorrect Option Analysis:
• A: Delays treatment; infection must not be observed
without escalation.
• C: Acetaminophen may mask fever and delay diagnosis.
• D: Nutrition support is helpful, but not the priority.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation / Safety and
Infection Control
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, recent chemotherapy
Expected Outcome: Patient remains free from sepsis, and
antimicrobial treatment is initiated promptly.
Key Learning Objective: Recognize neutropenic fever as an
urgent oncology complication requiring immediate action.
2) SATA — Cancer Care
, Clinical Scenario:
A patient receiving outpatient chemotherapy asks how to
reduce complications at home.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Report a temperature of 38°C (100.4°F) or higher
immediately
B. Use a soft toothbrush and electric razor
C. Eat raw, unwashed fruits and vegetables to increase vitamins
D. Take prescribed antiemetics before nausea becomes severe
E. Wash hands frequently and avoid exposure to sick contacts
Correct Answers:
A, B, D, E
Detailed Rationale:
These interventions reduce the risk of infection, bleeding, and
uncontrolled nausea. Early reporting of fever is critical because
immunosuppressed patients may deteriorate quickly.
Incorrect Option Analysis:
• C: Unwashed produce increases infection risk during
immunosuppression.
• A: Correct; prevents delay in care.
