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
Clinical Scenario:
A patient receiving chemotherapy for colorectal cancer reports
new fever, chills, and sore throat 8 days after treatment. The
nurse notes a temperature of 38.6°C (101.5°F) and an absolute
neutrophil count of 400/mm³.
Question Stem:
Which nursing action is the priority?
Answer Options:
A. Encourage oral fluids and rest
B. Place the patient on protective isolation and notify the
provider
C. Administer an antipyretic and reassess in 1 hour
D. Teach the patient to use a soft toothbrush
Correct Answer:
B. Place the patient on protective isolation and notify the
provider
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency
because neutropenia greatly increases the risk of overwhelming
infection. Immediate infection-control precautions and provider
notification are the priority. Cultures and empiric antibiotics are
typically initiated rapidly.
,Incorrect Option Analysis:
• A: Hydration helps support recovery, but does not address
the immediate life-threatening risk. Misconception:
supportive care is enough for fever in neutropenia.
• C: Antipyretics may mask worsening infection and delay
treatment. Safety concern: delayed intervention in sepsis
risk.
• D: Soft toothbrush teaching is appropriate for mucosal
protection, but not the priority now.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Safety and Infection Control; Physiological
Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Chemotherapy-induced neutropenia, mucosal
injury, immunosuppression
Expected Outcome:
The patient will receive rapid infection precautions and
appropriate treatment within minutes of fever recognition.
, Key Learning Objective:
Identify and act on life-threatening infection risk in
immunosuppressed patients.
2) SATA
Clinical Scenario:
A patient is starting immune checkpoint inhibitor therapy for
metastatic melanoma.
Question Stem:
Which findings should the nurse teach the patient to report
immediately? Select all that apply.
Answer Options:
A. New cough or shortness of breath
B. Persistent diarrhea
C. Mild hair thinning
D. Yellowing of the skin or eyes
E. Increased thirst and urination
F. Temporary fatigue after treatment
Correct Answers:
A, B, D, E
Detailed Rationale:
Immune checkpoint inhibitors can cause immune-related
adverse events affecting the lungs, bowel, liver, and endocrine
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
Clinical Scenario:
A patient receiving chemotherapy for colorectal cancer reports
new fever, chills, and sore throat 8 days after treatment. The
nurse notes a temperature of 38.6°C (101.5°F) and an absolute
neutrophil count of 400/mm³.
Question Stem:
Which nursing action is the priority?
Answer Options:
A. Encourage oral fluids and rest
B. Place the patient on protective isolation and notify the
provider
C. Administer an antipyretic and reassess in 1 hour
D. Teach the patient to use a soft toothbrush
Correct Answer:
B. Place the patient on protective isolation and notify the
provider
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency
because neutropenia greatly increases the risk of overwhelming
infection. Immediate infection-control precautions and provider
notification are the priority. Cultures and empiric antibiotics are
typically initiated rapidly.
,Incorrect Option Analysis:
• A: Hydration helps support recovery, but does not address
the immediate life-threatening risk. Misconception:
supportive care is enough for fever in neutropenia.
• C: Antipyretics may mask worsening infection and delay
treatment. Safety concern: delayed intervention in sepsis
risk.
• D: Soft toothbrush teaching is appropriate for mucosal
protection, but not the priority now.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Safety and Infection Control; Physiological
Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Chemotherapy-induced neutropenia, mucosal
injury, immunosuppression
Expected Outcome:
The patient will receive rapid infection precautions and
appropriate treatment within minutes of fever recognition.
, Key Learning Objective:
Identify and act on life-threatening infection risk in
immunosuppressed patients.
2) SATA
Clinical Scenario:
A patient is starting immune checkpoint inhibitor therapy for
metastatic melanoma.
Question Stem:
Which findings should the nurse teach the patient to report
immediately? Select all that apply.
Answer Options:
A. New cough or shortness of breath
B. Persistent diarrhea
C. Mild hair thinning
D. Yellowing of the skin or eyes
E. Increased thirst and urination
F. Temporary fatigue after treatment
Correct Answers:
A, B, D, E
Detailed Rationale:
Immune checkpoint inhibitors can cause immune-related
adverse events affecting the lungs, bowel, liver, and endocrine
