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 58-year-old patient is 10 days post-chemotherapy for
lymphoma. The patient reports chills, and the nurse records a
temperature of 38.6°C (101.5°F).
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and recheck the temperature in 1 hour
B. Place the patient on protective precautions and notify the
oncology provider immediately
C. Administer acetaminophen and document the response
D. Teach the patient to avoid crowds at home
Correct Answer:
B
Detailed Rationale:
Fever after chemotherapy may indicate febrile neutropenia,
which is an oncologic emergency. The nurse should act
immediately to reduce infection risk and escalate care.
Protective precautions and prompt provider notification
support rapid diagnostic workup and antibiotics.
Incorrect Option Analysis:
, • A: Delays urgent treatment; fever in an
immunocompromised patient requires immediate
escalation.
• C: Acetaminophen may mask fever and delay recognition
of sepsis.
• D: Avoiding crowds is helpful education, but not the
priority in this acute situation.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Safety and Infection Control; Physiological Adaptation
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Chemotherapy-induced neutropenia, impaired
immune defense
Defining Characteristics: Fever, chills
, Expected Outcome:
The patient will receive prompt evaluation and treatment for
possible neutropenic infection within the first hour of
recognition.
Key Learning Objective:
Identify and respond to oncologic infection emergencies using
clinical judgment and patient-safety priorities.
2) SATA
Clinical Scenario:
A patient receiving an immune checkpoint inhibitor for
metastatic melanoma reports new symptoms during an infusion
follow-up visit.
Question Stem:
Which findings should the nurse report immediately as possible
immune-related adverse effects? Select all that apply.
Answer Options:
A. New dry cough and shortness of breath
B. Persistent diarrhea
C. Yellowing of the skin and dark urine
D. Mild fatigue after a busy day
E. New headache with blurred vision
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 58-year-old patient is 10 days post-chemotherapy for
lymphoma. The patient reports chills, and the nurse records a
temperature of 38.6°C (101.5°F).
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and recheck the temperature in 1 hour
B. Place the patient on protective precautions and notify the
oncology provider immediately
C. Administer acetaminophen and document the response
D. Teach the patient to avoid crowds at home
Correct Answer:
B
Detailed Rationale:
Fever after chemotherapy may indicate febrile neutropenia,
which is an oncologic emergency. The nurse should act
immediately to reduce infection risk and escalate care.
Protective precautions and prompt provider notification
support rapid diagnostic workup and antibiotics.
Incorrect Option Analysis:
, • A: Delays urgent treatment; fever in an
immunocompromised patient requires immediate
escalation.
• C: Acetaminophen may mask fever and delay recognition
of sepsis.
• D: Avoiding crowds is helpful education, but not the
priority in this acute situation.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Safety and Infection Control; Physiological Adaptation
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Chemotherapy-induced neutropenia, impaired
immune defense
Defining Characteristics: Fever, chills
, Expected Outcome:
The patient will receive prompt evaluation and treatment for
possible neutropenic infection within the first hour of
recognition.
Key Learning Objective:
Identify and respond to oncologic infection emergencies using
clinical judgment and patient-safety priorities.
2) SATA
Clinical Scenario:
A patient receiving an immune checkpoint inhibitor for
metastatic melanoma reports new symptoms during an infusion
follow-up visit.
Question Stem:
Which findings should the nurse report immediately as possible
immune-related adverse effects? Select all that apply.
Answer Options:
A. New dry cough and shortness of breath
B. Persistent diarrhea
C. Yellowing of the skin and dark urine
D. Mild fatigue after a busy day
E. New headache with blurred vision
