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
,Chapter 1: Cancer Care
1) MCQ
Clinical scenario: A patient receiving myelosuppressive
chemotherapy calls the clinic on day 10 after treatment and
reports a temperature of 38.4°C (101.1°F), chills, and severe
fatigue. The most recent ANC was 400/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Tell the patient to rest and recheck the temperature in 4
hours.
B. Instruct the patient to come in immediately for cultures and
IV broad-spectrum antibiotics.
C. Encourage the patient to increase oral fluids and monitor for
diarrhea.
D. Advise the patient to take acetaminophen and notify the
provider tomorrow.
Correct answer: B
Detailed rationale: This is febrile neutropenia, a medical
emergency. The patient has a fever with profound neutropenia,
placing them at high risk for rapid sepsis. Priority care is
immediate evaluation, cultures, and prompt antibiotics.
Incorrect option analysis:
, • A: Unsafe delay; fever in neutropenia must not be watched
at home. Common misconception: assuming fever is minor
if the patient “looks okay.”
• C: Fluids matter, but infection management is the priority.
• D: Acetaminophen can mask fever and delay treatment;
waiting until tomorrow is unsafe.
Nursing process link: Implementation
NCJMM competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration: Risk for infection r/t
immunosuppression secondary to chemotherapy; defining
characteristic: fever with ANC 400/mm³
Expected outcome: Patient receives cultures and IV antibiotics
within the recommended time frame and remains
hemodynamically stable
Key learning objective: Prioritize emergency interventions for
chemotherapy-related neutropenia
2) SATA
, Clinical scenario: A patient is receiving external beam radiation
to the chest wall and asks how to care for the skin in the
treatment area.
Question stem: Which instructions should the nurse include?
Select all that apply.
Answer options:
A. Wash the area with lukewarm water and mild soap.
B. Apply adhesive tape directly over the treated skin.
C. Protect the area from direct sunlight.
D. Use deodorant or perfume on the treated skin.
E. Wear loose, soft clothing.
F. Preserve the skin markings unless the radiation team instructs
otherwise.
Correct answers: A, C, E, F
Detailed rationale: Radiation skin care is gentle skin care. The
nurse should prevent irritation, friction, and sun exposure, and
the patient should avoid removing or altering treatment
markings unless instructed.
Incorrect option analysis:
• B: Adhesive tape can damage fragile irradiated skin.
• D: Perfumes/deodorants can irritate treated tissue.
Common misconception: that “normal skin care” is
acceptable during radiation; it is not.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,Chapter 1: Cancer Care
1) MCQ
Clinical scenario: A patient receiving myelosuppressive
chemotherapy calls the clinic on day 10 after treatment and
reports a temperature of 38.4°C (101.1°F), chills, and severe
fatigue. The most recent ANC was 400/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Tell the patient to rest and recheck the temperature in 4
hours.
B. Instruct the patient to come in immediately for cultures and
IV broad-spectrum antibiotics.
C. Encourage the patient to increase oral fluids and monitor for
diarrhea.
D. Advise the patient to take acetaminophen and notify the
provider tomorrow.
Correct answer: B
Detailed rationale: This is febrile neutropenia, a medical
emergency. The patient has a fever with profound neutropenia,
placing them at high risk for rapid sepsis. Priority care is
immediate evaluation, cultures, and prompt antibiotics.
Incorrect option analysis:
, • A: Unsafe delay; fever in neutropenia must not be watched
at home. Common misconception: assuming fever is minor
if the patient “looks okay.”
• C: Fluids matter, but infection management is the priority.
• D: Acetaminophen can mask fever and delay treatment;
waiting until tomorrow is unsafe.
Nursing process link: Implementation
NCJMM competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration: Risk for infection r/t
immunosuppression secondary to chemotherapy; defining
characteristic: fever with ANC 400/mm³
Expected outcome: Patient receives cultures and IV antibiotics
within the recommended time frame and remains
hemodynamically stable
Key learning objective: Prioritize emergency interventions for
chemotherapy-related neutropenia
2) SATA
, Clinical scenario: A patient is receiving external beam radiation
to the chest wall and asks how to care for the skin in the
treatment area.
Question stem: Which instructions should the nurse include?
Select all that apply.
Answer options:
A. Wash the area with lukewarm water and mild soap.
B. Apply adhesive tape directly over the treated skin.
C. Protect the area from direct sunlight.
D. Use deodorant or perfume on the treated skin.
E. Wear loose, soft clothing.
F. Preserve the skin markings unless the radiation team instructs
otherwise.
Correct answers: A, C, E, F
Detailed rationale: Radiation skin care is gentle skin care. The
nurse should prevent irritation, friction, and sun exposure, and
the patient should avoid removing or altering treatment
markings unless instructed.
Incorrect option analysis:
• B: Adhesive tape can damage fragile irradiated skin.
• D: Perfumes/deodorants can irritate treated tissue.
Common misconception: that “normal skin care” is
acceptable during radiation; it is not.
