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
1. Question Number and Type
Question 1 — MCQ
2. Clinical Scenario
A 56-year-old patient receiving chemotherapy for colon cancer
calls the clinic and reports a temperature of 38.6°C (101.5°F),
chills, and weakness.
3. Question Stem
Which nursing action is the priority?
4. Answer Options
A. Tell the patient to take acetaminophen and rest at home
B. Instruct the patient to increase oral fluids and monitor
temperature later
C. Advise the patient to come to the emergency department
immediately
D. Teach the patient that fever is expected during
chemotherapy
5. Correct Answer
C. Advise the patient to come to the emergency department
immediately
6. Detailed Rationale
,A fever in a patient receiving chemotherapy may indicate febrile
neutropenia, which is a medical emergency because the
immune response may be severely impaired. The patient needs
immediate evaluation, cultures, and prompt treatment. Patient
safety and infection control take priority.
7. Incorrect Option Analysis
• A. Acetaminophen may lower fever but can delay urgent
evaluation.
Misconception: fever during chemo is harmless if the
patient feels “okay.”
Safety issue: delayed treatment of sepsis/neutropenia.
• B. Hydration is helpful, but this response is not sufficient
for possible neutropenic fever.
Misconception: supportive self-care is enough for infection
symptoms.
• D. Fever is not expected as a normal chemotherapy effect
requiring no action.
Misconception: confusing treatment side effects with
emergency warning signs.
8. Nursing Process Linkage
Implementation
9. Clinical Judgment Competencies (NCJMM)
Recognize Cues; Prioritize Hypotheses; Take Action
, 10. Difficulty Level
Difficult
11. Bloom’s Cognitive Level
Analyze
12. NCLEX Client Needs Category
Physiological Adaptation
13. Nursing Diagnosis Integration
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppression, chemotherapy treatment,
fever
14. Expected Outcome
The patient will receive emergency evaluation and treatment
within a clinically appropriate timeframe to reduce the risk of
sepsis.
15. Key Learning Objective
Identify urgent infection-related complications in chemotherapy
patients and prioritize immediate action.
2) MCQ
1. Question Number and Type
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
1. Question Number and Type
Question 1 — MCQ
2. Clinical Scenario
A 56-year-old patient receiving chemotherapy for colon cancer
calls the clinic and reports a temperature of 38.6°C (101.5°F),
chills, and weakness.
3. Question Stem
Which nursing action is the priority?
4. Answer Options
A. Tell the patient to take acetaminophen and rest at home
B. Instruct the patient to increase oral fluids and monitor
temperature later
C. Advise the patient to come to the emergency department
immediately
D. Teach the patient that fever is expected during
chemotherapy
5. Correct Answer
C. Advise the patient to come to the emergency department
immediately
6. Detailed Rationale
,A fever in a patient receiving chemotherapy may indicate febrile
neutropenia, which is a medical emergency because the
immune response may be severely impaired. The patient needs
immediate evaluation, cultures, and prompt treatment. Patient
safety and infection control take priority.
7. Incorrect Option Analysis
• A. Acetaminophen may lower fever but can delay urgent
evaluation.
Misconception: fever during chemo is harmless if the
patient feels “okay.”
Safety issue: delayed treatment of sepsis/neutropenia.
• B. Hydration is helpful, but this response is not sufficient
for possible neutropenic fever.
Misconception: supportive self-care is enough for infection
symptoms.
• D. Fever is not expected as a normal chemotherapy effect
requiring no action.
Misconception: confusing treatment side effects with
emergency warning signs.
8. Nursing Process Linkage
Implementation
9. Clinical Judgment Competencies (NCJMM)
Recognize Cues; Prioritize Hypotheses; Take Action
, 10. Difficulty Level
Difficult
11. Bloom’s Cognitive Level
Analyze
12. NCLEX Client Needs Category
Physiological Adaptation
13. Nursing Diagnosis Integration
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppression, chemotherapy treatment,
fever
14. Expected Outcome
The patient will receive emergency evaluation and treatment
within a clinically appropriate timeframe to reduce the risk of
sepsis.
15. Key Learning Objective
Identify urgent infection-related complications in chemotherapy
patients and prioritize immediate action.
2) MCQ
1. Question Number and Type
