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 client is 9 days after the first cycle of
chemotherapy and reports sore throat and chills. Temperature
is 38.2°C (100.8°F); ANC is 480/mm³.
Stem: What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 4 hours.
B. Place the client on neutropenic precautions and notify the
provider immediately.
C. Encourage oral fluids and ambulation.
D. Administer an iron supplement as prescribed.
Correct answer: B
Rationale: Fever with severe neutropenia is an emergency
because the client may deteriorate rapidly from infection.
Immediate infection protection and provider notification
support prompt cultures and IV antibiotics if ordered.
Incorrect options:
A is unsafe because it can mask fever and delay treatment.
C does not address the immediate infection risk.
D is unrelated to the acute problem.
Nursing process link: Implementation
NCJMM: Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Difficult
,Bloom’s level: Analyze
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Risk for infection r/t
myelosuppression
Expected outcome: The client remains free of sepsis and
receives timely infection management within the shift.
Key learning objective: Prioritize care for febrile neutropenia
after chemotherapy.
2) MCQ — Cancer Care
Clinical scenario: A client is receiving external beam radiation to
the chest wall.
Stem: Which statement shows correct understanding of
radiation skin care?
Answer options:
A. “I will scrub the area well with soap and a washcloth.”
B. “I can use a heating pad to relieve discomfort.”
C. “I will wash gently with lukewarm water and pat the skin dry.”
D. “I should apply lotion right before each treatment.”
Correct answer: C
Rationale: Radiation skin should be handled gently to prevent
irritation and breakdown. Lukewarm water and patting dry
reduce trauma to fragile tissue.
, Incorrect options:
A causes friction and may worsen skin injury.
B can increase tissue damage because heat should be avoided
on irradiated skin.
D may interfere with treatment delivery or irritate skin;
products should only be used if approved by the oncology
team.
Nursing process link: Teaching/Implementation
NCJMM: Take Action; Evaluate Outcomes
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Basic Care and Comfort; Reduction of Risk
Potential
Nursing diagnosis integration: Risk for impaired skin integrity
r/t radiation exposure
Expected outcome: The client verbalizes correct skin-care
measures and maintains intact irradiated skin.
Key learning objective: Identify safe self-care measures during
radiation therapy.
3) MCQ — Cancer Care
Clinical scenario: A client receiving an immune checkpoint
inhibitor calls the clinic and reports watery diarrhea six times
today and new abdominal cramping.
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 client is 9 days after the first cycle of
chemotherapy and reports sore throat and chills. Temperature
is 38.2°C (100.8°F); ANC is 480/mm³.
Stem: What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 4 hours.
B. Place the client on neutropenic precautions and notify the
provider immediately.
C. Encourage oral fluids and ambulation.
D. Administer an iron supplement as prescribed.
Correct answer: B
Rationale: Fever with severe neutropenia is an emergency
because the client may deteriorate rapidly from infection.
Immediate infection protection and provider notification
support prompt cultures and IV antibiotics if ordered.
Incorrect options:
A is unsafe because it can mask fever and delay treatment.
C does not address the immediate infection risk.
D is unrelated to the acute problem.
Nursing process link: Implementation
NCJMM: Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Difficult
,Bloom’s level: Analyze
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Risk for infection r/t
myelosuppression
Expected outcome: The client remains free of sepsis and
receives timely infection management within the shift.
Key learning objective: Prioritize care for febrile neutropenia
after chemotherapy.
2) MCQ — Cancer Care
Clinical scenario: A client is receiving external beam radiation to
the chest wall.
Stem: Which statement shows correct understanding of
radiation skin care?
Answer options:
A. “I will scrub the area well with soap and a washcloth.”
B. “I can use a heating pad to relieve discomfort.”
C. “I will wash gently with lukewarm water and pat the skin dry.”
D. “I should apply lotion right before each treatment.”
Correct answer: C
Rationale: Radiation skin should be handled gently to prevent
irritation and breakdown. Lukewarm water and patting dry
reduce trauma to fragile tissue.
, Incorrect options:
A causes friction and may worsen skin injury.
B can increase tissue damage because heat should be avoided
on irradiated skin.
D may interfere with treatment delivery or irritate skin;
products should only be used if approved by the oncology
team.
Nursing process link: Teaching/Implementation
NCJMM: Take Action; Evaluate Outcomes
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Basic Care and Comfort; Reduction of Risk
Potential
Nursing diagnosis integration: Risk for impaired skin integrity
r/t radiation exposure
Expected outcome: The client verbalizes correct skin-care
measures and maintains intact irradiated skin.
Key learning objective: Identify safe self-care measures during
radiation therapy.
3) MCQ — Cancer Care
Clinical scenario: A client receiving an immune checkpoint
inhibitor calls the clinic and reports watery diarrhea six times
today and new abdominal cramping.
