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 58-year-old client with colorectal cancer received their last
chemotherapy cycle 10 days ago. They now have a temperature
of 38.6°C (101.5°F), a sore throat, and a white blood cell count
that is below the expected range.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Initiate neutropenic precautions and notify the oncology
provider immediately
B. Give an antipyretic and reassess the temperature in 1 hour
C. Encourage the client to ambulate to improve circulation
D. Restrict oral fluids until repeat laboratory results are
available
Correct Answer:
A
Detailed Rationale:
Fever after chemotherapy is a medical emergency because it
may indicate neutropenic infection. The safest first nursing
response is to implement infection-protective measures and
,notify the provider promptly so cultures and empiric antibiotics
can be started quickly.
Incorrect Option Analysis:
B. Incorrect. Antipyretics can mask worsening infection and
delay urgent treatment.
C. Incorrect. Ambulation does not address the immediate
infection risk.
D. Incorrect. Fluids should not be restricted unless there is a
specific contraindication; dehydration can worsen clinical status.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Safety and Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppression, chemotherapy exposure, low
WBC count
, Expected Outcome:
The client will remain free from sepsis and receive prompt
infection management within the current care episode.
Key Learning Objective:
Identify and respond to neutropenic fever as a time-sensitive
oncology safety problem.
2) SATA
Clinical Scenario:
A client is receiving radiation therapy for head and neck cancer.
Question Stem:
Which instructions should the nurse include in the teaching
plan? Select all that apply.
Answer Options:
A. Wash the treated skin gently with mild soap and lukewarm
water
B. Use scented lotions on the treatment area before each
session
C. Protect the treated skin from direct sunlight
D. Wear loose, soft clothing over the treatment area
E. Rub the skin vigorously after bathing
F. Avoid adhesive tape on the irradiated skin when possible
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 58-year-old client with colorectal cancer received their last
chemotherapy cycle 10 days ago. They now have a temperature
of 38.6°C (101.5°F), a sore throat, and a white blood cell count
that is below the expected range.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Initiate neutropenic precautions and notify the oncology
provider immediately
B. Give an antipyretic and reassess the temperature in 1 hour
C. Encourage the client to ambulate to improve circulation
D. Restrict oral fluids until repeat laboratory results are
available
Correct Answer:
A
Detailed Rationale:
Fever after chemotherapy is a medical emergency because it
may indicate neutropenic infection. The safest first nursing
response is to implement infection-protective measures and
,notify the provider promptly so cultures and empiric antibiotics
can be started quickly.
Incorrect Option Analysis:
B. Incorrect. Antipyretics can mask worsening infection and
delay urgent treatment.
C. Incorrect. Ambulation does not address the immediate
infection risk.
D. Incorrect. Fluids should not be restricted unless there is a
specific contraindication; dehydration can worsen clinical status.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Safety and Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppression, chemotherapy exposure, low
WBC count
, Expected Outcome:
The client will remain free from sepsis and receive prompt
infection management within the current care episode.
Key Learning Objective:
Identify and respond to neutropenic fever as a time-sensitive
oncology safety problem.
2) SATA
Clinical Scenario:
A client is receiving radiation therapy for head and neck cancer.
Question Stem:
Which instructions should the nurse include in the teaching
plan? Select all that apply.
Answer Options:
A. Wash the treated skin gently with mild soap and lukewarm
water
B. Use scented lotions on the treatment area before each
session
C. Protect the treated skin from direct sunlight
D. Wear loose, soft clothing over the treatment area
E. Rub the skin vigorously after bathing
F. Avoid adhesive tape on the irradiated skin when possible
