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 client is 8 days post-chemotherapy for lymphoma and arrives
at the clinic reporting chills and fatigue. Temperature is 38.4°C
(101.1°F), heart rate is 112/min, and absolute neutrophil count
is 450/mm³.
Question stem:
What should the nurse do first?
Answer options:
A. Give acetaminophen and encourage rest
B. Place the client on protective precautions and notify the
oncology provider immediately
C. Encourage the client to increase fresh fruits and salads
D. Reassure the client that fever is expected after chemotherapy
Correct answer:
B
Detailed rationale:
This client has febrile neutropenia, which is a medical
emergency because infection can progress rapidly to sepsis. The
nurse should immediately reduce exposure risk and notify the
provider so cultures and empiric antibiotics can be started
promptly.
Incorrect option analysis:
, • A is incorrect because fever in neutropenia is not treated
as a routine symptom; masking it delays urgent care.
• C is incorrect because raw fruits and vegetables may
increase infection risk in neutropenic clients.
• D is incorrect because fever is not expected or benign after
chemotherapy in a neutropenic client.
Nursing process link: Assessment
NCJMM competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
Priority diagnosis: Risk for infection
Risk factors: chemotherapy-induced immunosuppression,
neutropenia, fever
Expected outcome:
The client will receive timely infection-focused intervention and
will not show signs of hemodynamic instability or worsening
infection.
Key learning objective:
Identify neutropenic fever as a high-priority safety issue and
initiate urgent infection-control actions.
, 2) SATA
Clinical scenario:
A client is being discharged after the first cycle of chemotherapy
and also receives immune checkpoint inhibitor therapy.
Question stem:
Which statements by the client show correct understanding of
home care? Select all that apply.
Answer options:
A. “I should report a temperature of 38°C (100.4°F) or higher
right away.”
B. “Using a soft toothbrush and an electric razor will help
reduce bleeding risk.”
C. “If I develop new cough, shortness of breath, or diarrhea, I
should contact the clinic.”
D. “I should apply lotion, powder, or deodorant directly before
radiation to protect my skin.”
E. “Staying hydrated and eating small frequent meals can help
me cope with nausea.”
Correct answers:
A, B, C, E
Detailed rationale:
These teaching points support infection prevention, bleeding
prevention, early recognition of immune-related adverse
events, and symptom management. New cough or shortness of
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 client is 8 days post-chemotherapy for lymphoma and arrives
at the clinic reporting chills and fatigue. Temperature is 38.4°C
(101.1°F), heart rate is 112/min, and absolute neutrophil count
is 450/mm³.
Question stem:
What should the nurse do first?
Answer options:
A. Give acetaminophen and encourage rest
B. Place the client on protective precautions and notify the
oncology provider immediately
C. Encourage the client to increase fresh fruits and salads
D. Reassure the client that fever is expected after chemotherapy
Correct answer:
B
Detailed rationale:
This client has febrile neutropenia, which is a medical
emergency because infection can progress rapidly to sepsis. The
nurse should immediately reduce exposure risk and notify the
provider so cultures and empiric antibiotics can be started
promptly.
Incorrect option analysis:
, • A is incorrect because fever in neutropenia is not treated
as a routine symptom; masking it delays urgent care.
• C is incorrect because raw fruits and vegetables may
increase infection risk in neutropenic clients.
• D is incorrect because fever is not expected or benign after
chemotherapy in a neutropenic client.
Nursing process link: Assessment
NCJMM competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
Priority diagnosis: Risk for infection
Risk factors: chemotherapy-induced immunosuppression,
neutropenia, fever
Expected outcome:
The client will receive timely infection-focused intervention and
will not show signs of hemodynamic instability or worsening
infection.
Key learning objective:
Identify neutropenic fever as a high-priority safety issue and
initiate urgent infection-control actions.
, 2) SATA
Clinical scenario:
A client is being discharged after the first cycle of chemotherapy
and also receives immune checkpoint inhibitor therapy.
Question stem:
Which statements by the client show correct understanding of
home care? Select all that apply.
Answer options:
A. “I should report a temperature of 38°C (100.4°F) or higher
right away.”
B. “Using a soft toothbrush and an electric razor will help
reduce bleeding risk.”
C. “If I develop new cough, shortness of breath, or diarrhea, I
should contact the clinic.”
D. “I should apply lotion, powder, or deodorant directly before
radiation to protect my skin.”
E. “Staying hydrated and eating small frequent meals can help
me cope with nausea.”
Correct answers:
A, B, C, E
Detailed rationale:
These teaching points support infection prevention, bleeding
prevention, early recognition of immune-related adverse
events, and symptom management. New cough or shortness of
