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: Febrile Neutropenia
Clinical Scenario:
A 62-year-old client receiving myelosuppressive chemotherapy
calls the clinic and reports chills, fatigue, and a temperature of
38.4°C (101.1°F). The client’s absolute neutrophil count from
this morning is 700/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Tell the client to take acetaminophen and recheck the
temperature in 4 hours
B. Instruct the client to avoid visitors and increase oral fluids at
home
C. Obtain blood cultures per protocol and prepare to start
broad-spectrum IV antibiotics
D. Reassure the client that a mild fever is expected after
chemotherapy
Correct Answer:
C
Detailed Rationale:
Fever with neutropenia is an oncologic emergency because the
client may not be able to mount an effective immune response.
The priority is rapid sepsis prevention: cultures and prompt
,antibiotics per protocol. Delays increase risk for shock and
death.
Incorrect Option Analysis:
• A: Incorrect. Acetaminophen may mask worsening
infection and delays treatment.
• B: Incorrect. Neutropenic precautions are important, but
they do not replace urgent treatment.
• D: Incorrect. Fever is never treated as expected in a
neutropenic client.
Nursing Process Linkage: Assessment/Implementation
NCJMM: Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation; Safety and
Infection Control
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, chemotherapy
Expected Outcome: Blood cultures are obtained and IV
antibiotics begin within the institution’s febrile
neutropenia protocol time frame.
Key Learning Objective: Identify and act on life-
threatening infection risk in immunosuppressed clients.
, 2) SATA — Cancer Care: Chemotherapy Teaching
Clinical Scenario:
A client is discharged after the first cycle of chemotherapy and
asks what to do at home to reduce complications.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Use a soft toothbrush for oral care
B. Report a temperature of 38°C (100.4°F) or higher
C. Eat raw seafood to improve protein intake
D. Perform frequent hand hygiene and avoid close contact with
sick people
E. Take aspirin for headaches without checking with the
oncology team
F. Use an electric razor instead of blades if shaving is necessary
Correct Answers:
A, B, D, F
Detailed Rationale:
Chemotherapy can cause mucositis, thrombocytopenia, and
neutropenia. Gentle oral care, fever reporting, infection
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care: Febrile Neutropenia
Clinical Scenario:
A 62-year-old client receiving myelosuppressive chemotherapy
calls the clinic and reports chills, fatigue, and a temperature of
38.4°C (101.1°F). The client’s absolute neutrophil count from
this morning is 700/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Tell the client to take acetaminophen and recheck the
temperature in 4 hours
B. Instruct the client to avoid visitors and increase oral fluids at
home
C. Obtain blood cultures per protocol and prepare to start
broad-spectrum IV antibiotics
D. Reassure the client that a mild fever is expected after
chemotherapy
Correct Answer:
C
Detailed Rationale:
Fever with neutropenia is an oncologic emergency because the
client may not be able to mount an effective immune response.
The priority is rapid sepsis prevention: cultures and prompt
,antibiotics per protocol. Delays increase risk for shock and
death.
Incorrect Option Analysis:
• A: Incorrect. Acetaminophen may mask worsening
infection and delays treatment.
• B: Incorrect. Neutropenic precautions are important, but
they do not replace urgent treatment.
• D: Incorrect. Fever is never treated as expected in a
neutropenic client.
Nursing Process Linkage: Assessment/Implementation
NCJMM: Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation; Safety and
Infection Control
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, chemotherapy
Expected Outcome: Blood cultures are obtained and IV
antibiotics begin within the institution’s febrile
neutropenia protocol time frame.
Key Learning Objective: Identify and act on life-
threatening infection risk in immunosuppressed clients.
, 2) SATA — Cancer Care: Chemotherapy Teaching
Clinical Scenario:
A client is discharged after the first cycle of chemotherapy and
asks what to do at home to reduce complications.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Use a soft toothbrush for oral care
B. Report a temperature of 38°C (100.4°F) or higher
C. Eat raw seafood to improve protein intake
D. Perform frequent hand hygiene and avoid close contact with
sick people
E. Take aspirin for headaches without checking with the
oncology team
F. Use an electric razor instead of blades if shaving is necessary
Correct Answers:
A, B, D, F
Detailed Rationale:
Chemotherapy can cause mucositis, thrombocytopenia, and
neutropenia. Gentle oral care, fever reporting, infection
