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 62-year-old client with lymphoma is receiving cycle 2 of
chemotherapy. The client reports chills and feeling “flu-like.”
Vital signs are temperature 38.6°C (101.5°F), HR 118/min, BP
96/58 mm Hg, and ANC is 700/mm³.
Question Stem
What is the priority nursing action?
Answer Options
A. Encourage oral fluids and recheck the temperature in 1 hour
B. Place the client on protective precautions and notify the
oncology provider immediately
C. Give acetaminophen and document the findings
D. Teach the client to avoid spicy foods until the next visit
Correct Answer
B
Detailed Rationale
This client has febrile neutropenia, which is an emergency
because infection can progress rapidly with a low ANC. The
nurse should initiate protective precautions and notify the
oncology provider immediately so cultures and broad-spectrum
antibiotics can be started quickly.
,Incorrect Option Analysis
• A. Delays intervention. Oral fluids alone do not address
possible sepsis.
• C. Acetaminophen may mask fever and delay care.
• D. Spicy food teaching is unrelated to the urgent problem.
Nursing Process Linkage
Implementation
Clinical Judgment Competencies (NCJMM)
Recognize Cues; Analyze 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: Neutropenia, chemotherapy, fever, chills
Expected Outcome
, The client will receive prompt evaluation and treatment for
possible infection with no progression to hemodynamic
instability.
Key Learning Objective
Identify urgent complications of chemotherapy and select the
safest priority nursing response.
2) SATA — Cancer Care
Clinical Scenario
A client is receiving external beam radiation therapy to the
chest.
Question Stem
Which statements by the client indicate correct understanding
of radiation self-care? Select all that apply.
Answer Options
A. “I will wash the area gently with lukewarm water and mild
soap.”
B. “I should apply perfumed lotion to the site before
treatment.”
C. “I will protect the area from direct sunlight.”
D. “I should wear loose, soft clothing over the site.”
E. “I will scrub off the treatment markings each day.”
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 62-year-old client with lymphoma is receiving cycle 2 of
chemotherapy. The client reports chills and feeling “flu-like.”
Vital signs are temperature 38.6°C (101.5°F), HR 118/min, BP
96/58 mm Hg, and ANC is 700/mm³.
Question Stem
What is the priority nursing action?
Answer Options
A. Encourage oral fluids and recheck the temperature in 1 hour
B. Place the client on protective precautions and notify the
oncology provider immediately
C. Give acetaminophen and document the findings
D. Teach the client to avoid spicy foods until the next visit
Correct Answer
B
Detailed Rationale
This client has febrile neutropenia, which is an emergency
because infection can progress rapidly with a low ANC. The
nurse should initiate protective precautions and notify the
oncology provider immediately so cultures and broad-spectrum
antibiotics can be started quickly.
,Incorrect Option Analysis
• A. Delays intervention. Oral fluids alone do not address
possible sepsis.
• C. Acetaminophen may mask fever and delay care.
• D. Spicy food teaching is unrelated to the urgent problem.
Nursing Process Linkage
Implementation
Clinical Judgment Competencies (NCJMM)
Recognize Cues; Analyze 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: Neutropenia, chemotherapy, fever, chills
Expected Outcome
, The client will receive prompt evaluation and treatment for
possible infection with no progression to hemodynamic
instability.
Key Learning Objective
Identify urgent complications of chemotherapy and select the
safest priority nursing response.
2) SATA — Cancer Care
Clinical Scenario
A client is receiving external beam radiation therapy to the
chest.
Question Stem
Which statements by the client indicate correct understanding
of radiation self-care? Select all that apply.
Answer Options
A. “I will wash the area gently with lukewarm water and mild
soap.”
B. “I should apply perfumed lotion to the site before
treatment.”
C. “I will protect the area from direct sunlight.”
D. “I should wear loose, soft clothing over the site.”
E. “I will scrub off the treatment markings each day.”
