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 receiving chemotherapy for colon cancer reports a
temperature of 38.5°C (101.3°F), sore throat, and chills. The
most recent absolute neutrophil count is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and rest
B. Place the client in a private room and initiate contact
precautions
C. Notify the oncology provider and prepare to obtain blood
cultures
D. Administer acetaminophen and reassess temperature in 1
hour
Correct Answer:
C
Detailed Rationale:
This client has febrile neutropenia, a medical emergency. The
priority is rapid escalation of care, including notifying the
provider and preparing for cultures and broad-spectrum
antibiotics per protocol. Fever in the setting of severe
neutropenia can indicate sepsis even when other signs are
subtle.
,Incorrect Option Analysis:
• A: Hydration is supportive but not the priority in suspected
neutropenic fever. Misconception: treating symptoms
before the underlying emergency.
• B: Protective precautions may be needed, but contact
precautions do not address the urgent infectious risk.
• D: Antipyretics can mask fever and delay treatment.
Patient safety concern: delayed sepsis management.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Chemotherapy-induced neutropenia,
impaired immune response
Expected Outcome: The client will receive prompt
evaluation and treatment for possible infection within the
institution’s febrile neutropenia protocol.
Key Learning Objective: Recognize and respond to life-
threatening infection risk in a chemotherapy client.
, 2) SATA — Cancer Care
Clinical Scenario:
A client is receiving external beam radiation therapy to the
chest wall after mastectomy.
Question Stem:
Which teaching points should the nurse include? Select all that
apply.
Answer Options:
A. Wash the skin gently with lukewarm water and mild soap
B. Apply heating pads to relieve discomfort in the treatment
area
C. Wear loose, soft clothing over the irradiated skin
D. Use only products approved by the radiation oncology team
on the skin
E. Rub the treatment site dry after bathing to remove dead skin
Correct Answers:
A, C, D
Detailed Rationale:
Radiation skin care focuses on preventing further tissue injury.
Gentle cleansing, loose clothing, and approved skin products
help reduce irritation. Heat, friction, and rubbing can worsen
radiation dermatitis.
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 receiving chemotherapy for colon cancer reports a
temperature of 38.5°C (101.3°F), sore throat, and chills. The
most recent absolute neutrophil count is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and rest
B. Place the client in a private room and initiate contact
precautions
C. Notify the oncology provider and prepare to obtain blood
cultures
D. Administer acetaminophen and reassess temperature in 1
hour
Correct Answer:
C
Detailed Rationale:
This client has febrile neutropenia, a medical emergency. The
priority is rapid escalation of care, including notifying the
provider and preparing for cultures and broad-spectrum
antibiotics per protocol. Fever in the setting of severe
neutropenia can indicate sepsis even when other signs are
subtle.
,Incorrect Option Analysis:
• A: Hydration is supportive but not the priority in suspected
neutropenic fever. Misconception: treating symptoms
before the underlying emergency.
• B: Protective precautions may be needed, but contact
precautions do not address the urgent infectious risk.
• D: Antipyretics can mask fever and delay treatment.
Patient safety concern: delayed sepsis management.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection
• Risk Factors: Chemotherapy-induced neutropenia,
impaired immune response
Expected Outcome: The client will receive prompt
evaluation and treatment for possible infection within the
institution’s febrile neutropenia protocol.
Key Learning Objective: Recognize and respond to life-
threatening infection risk in a chemotherapy client.
, 2) SATA — Cancer Care
Clinical Scenario:
A client is receiving external beam radiation therapy to the
chest wall after mastectomy.
Question Stem:
Which teaching points should the nurse include? Select all that
apply.
Answer Options:
A. Wash the skin gently with lukewarm water and mild soap
B. Apply heating pads to relieve discomfort in the treatment
area
C. Wear loose, soft clothing over the irradiated skin
D. Use only products approved by the radiation oncology team
on the skin
E. Rub the treatment site dry after bathing to remove dead skin
Correct Answers:
A, C, D
Detailed Rationale:
Radiation skin care focuses on preventing further tissue injury.
Gentle cleansing, loose clothing, and approved skin products
help reduce irritation. Heat, friction, and rubbing can worsen
radiation dermatitis.
