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 patient with breast cancer received the
second cycle of chemotherapy 10 days ago and now reports
fever, chills, and sore throat. The ANC is 450/mm³.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Encourage increased oral fluids and recheck the temperature
in 4 hours
B. Initiate neutropenic precautions and notify the oncology
provider immediately
C. Administer an antipyretic and document the response
D. Teach the patient to avoid crowds until the next
chemotherapy cycle
Correct Answer: B
Detailed Rationale: Fever with severe neutropenia suggests
febrile neutropenia, a medical emergency. The nurse must
reduce infection exposure and escalate care immediately so
cultures and antibiotics can be started promptly.
Incorrect Option Analysis:
A is incorrect because waiting delays treatment; the
misconception is that fever can be observed first.
C is incorrect because antipyretics may mask worsening
infection; patient safety concern is delayed recognition of
sepsis.
,D is incorrect because crowd avoidance is useful teaching, but it
does not address the current emergency.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Recognize Cues, Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Nursing Diagnosis Integration: Risk for infection related to
myelosuppression
Expected Outcome: The patient remains hemodynamically
stable and receives prompt evaluation and treatment for
suspected infection.
Key Learning Objective: Prioritize care for chemotherapy-
associated neutropenic fever.
2) SATA — Cancer Care
Clinical Scenario: A patient is receiving an immune checkpoint
inhibitor for metastatic melanoma.
Question Stem: Which findings should the nurse instruct the
patient to report immediately? Select all that apply.
Answer Options:
A. New-onset diarrhea
B. Mild fatigue after walking
, C. Shortness of breath
D. Dark urine or yellowing of the skin
E. Dry skin on the arms
Correct Answers: A, C, D
Detailed Rationale: Immune-related adverse effects can involve
the GI tract, lungs, liver, and other organs. New diarrhea,
dyspnea, and jaundice/dark urine may signal serious toxicity
requiring urgent assessment.
Incorrect Option Analysis:
B is incorrect because mild exertional fatigue is common and
nonspecific; the misconception is that all fatigue is urgent.
E is incorrect because dry skin alone is a less acute side effect
and usually not an emergency, though it still merits routine
reporting if persistent.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies: Recognize Cues, Analyze Cues
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Pharmacological and Parenteral Therapies
Nursing Diagnosis Integration: Risk for adverse effects of
treatment related to immunotherapy
Expected Outcome: The patient identifies and reports immune-
related toxicities early.
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 patient with breast cancer received the
second cycle of chemotherapy 10 days ago and now reports
fever, chills, and sore throat. The ANC is 450/mm³.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Encourage increased oral fluids and recheck the temperature
in 4 hours
B. Initiate neutropenic precautions and notify the oncology
provider immediately
C. Administer an antipyretic and document the response
D. Teach the patient to avoid crowds until the next
chemotherapy cycle
Correct Answer: B
Detailed Rationale: Fever with severe neutropenia suggests
febrile neutropenia, a medical emergency. The nurse must
reduce infection exposure and escalate care immediately so
cultures and antibiotics can be started promptly.
Incorrect Option Analysis:
A is incorrect because waiting delays treatment; the
misconception is that fever can be observed first.
C is incorrect because antipyretics may mask worsening
infection; patient safety concern is delayed recognition of
sepsis.
,D is incorrect because crowd avoidance is useful teaching, but it
does not address the current emergency.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Recognize Cues, Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Nursing Diagnosis Integration: Risk for infection related to
myelosuppression
Expected Outcome: The patient remains hemodynamically
stable and receives prompt evaluation and treatment for
suspected infection.
Key Learning Objective: Prioritize care for chemotherapy-
associated neutropenic fever.
2) SATA — Cancer Care
Clinical Scenario: A patient is receiving an immune checkpoint
inhibitor for metastatic melanoma.
Question Stem: Which findings should the nurse instruct the
patient to report immediately? Select all that apply.
Answer Options:
A. New-onset diarrhea
B. Mild fatigue after walking
, C. Shortness of breath
D. Dark urine or yellowing of the skin
E. Dry skin on the arms
Correct Answers: A, C, D
Detailed Rationale: Immune-related adverse effects can involve
the GI tract, lungs, liver, and other organs. New diarrhea,
dyspnea, and jaundice/dark urine may signal serious toxicity
requiring urgent assessment.
Incorrect Option Analysis:
B is incorrect because mild exertional fatigue is common and
nonspecific; the misconception is that all fatigue is urgent.
E is incorrect because dry skin alone is a less acute side effect
and usually not an emergency, though it still merits routine
reporting if persistent.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies: Recognize Cues, Analyze Cues
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Pharmacological and Parenteral Therapies
Nursing Diagnosis Integration: Risk for adverse effects of
treatment related to immunotherapy
Expected Outcome: The patient identifies and reports immune-
related toxicities early.
