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 58-year-old patient is receiving the second cycle of
chemotherapy for colorectal cancer. The patient calls the clinic
and reports a temperature of 38.4°C (101.1°F), chills, and new
fatigue. The absolute neutrophil count from this morning was
700/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Tell the patient to take acetaminophen and rest at home
B. Advise the patient to drink extra fluids and monitor the
temperature again in 4 hours
C. Instruct the patient to come to the clinic immediately for
evaluation of possible febrile neutropenia
D. Reassure the patient that fever is expected after
chemotherapy
Correct Answer:
C. Instruct the patient to come to the clinic immediately for
evaluation of possible febrile neutropenia
Detailed Rationale:
This patient has fever with neutropenia, which is a medical
emergency because infection may progress rapidly without
typical inflammatory signs. The nurse should treat this as
,possible febrile neutropenia and ensure prompt evaluation,
cultures, and early antibiotics. Delayed action increases the risk
of sepsis and death.
Incorrect Option Analysis:
• A: Acetaminophen can mask fever and delay urgent care.
Rest alone is unsafe.
• B: Hydration is helpful, but this situation requires
immediate assessment, not home monitoring.
• D: Fever is not an expected or normal response after
chemotherapy when neutropenia is present; this reflects a
dangerous misconception.
Nursing Process Linkage:
Assessment
NCJMM Clinical Judgment Competencies:
Recognize Cues; Analyze Cues; Prioritize Hypotheses
Difficulty Level:
Difficult
Bloom’s Taxonomy Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
, Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for infection
Risk Factors: neutropenia, chemotherapy, impaired immune
defenses
Expected Outcome:
Patient will receive urgent evaluation and prescribed
antimicrobial therapy within 1 hour of arrival to the clinic.
Key Learning Objective:
Identify febrile neutropenia as a high-priority oncology
emergency and respond with rapid escalation.
2) SATA — Cancer Care
Clinical Scenario:
A patient with breast cancer is being discharged after a
chemotherapy infusion. The patient asks what to do at home to
reduce complications from treatment-related
immunosuppression and oral mucosal irritation.
Question Stem:
Which discharge instructions should the nurse include? Select
all that apply.
Answer Options:
A. Use a soft toothbrush and gentle mouth rinses
B. Report a temperature of 38°C (100.4°F) or higher
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 58-year-old patient is receiving the second cycle of
chemotherapy for colorectal cancer. The patient calls the clinic
and reports a temperature of 38.4°C (101.1°F), chills, and new
fatigue. The absolute neutrophil count from this morning was
700/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Tell the patient to take acetaminophen and rest at home
B. Advise the patient to drink extra fluids and monitor the
temperature again in 4 hours
C. Instruct the patient to come to the clinic immediately for
evaluation of possible febrile neutropenia
D. Reassure the patient that fever is expected after
chemotherapy
Correct Answer:
C. Instruct the patient to come to the clinic immediately for
evaluation of possible febrile neutropenia
Detailed Rationale:
This patient has fever with neutropenia, which is a medical
emergency because infection may progress rapidly without
typical inflammatory signs. The nurse should treat this as
,possible febrile neutropenia and ensure prompt evaluation,
cultures, and early antibiotics. Delayed action increases the risk
of sepsis and death.
Incorrect Option Analysis:
• A: Acetaminophen can mask fever and delay urgent care.
Rest alone is unsafe.
• B: Hydration is helpful, but this situation requires
immediate assessment, not home monitoring.
• D: Fever is not an expected or normal response after
chemotherapy when neutropenia is present; this reflects a
dangerous misconception.
Nursing Process Linkage:
Assessment
NCJMM Clinical Judgment Competencies:
Recognize Cues; Analyze Cues; Prioritize Hypotheses
Difficulty Level:
Difficult
Bloom’s Taxonomy Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
, Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for infection
Risk Factors: neutropenia, chemotherapy, impaired immune
defenses
Expected Outcome:
Patient will receive urgent evaluation and prescribed
antimicrobial therapy within 1 hour of arrival to the clinic.
Key Learning Objective:
Identify febrile neutropenia as a high-priority oncology
emergency and respond with rapid escalation.
2) SATA — Cancer Care
Clinical Scenario:
A patient with breast cancer is being discharged after a
chemotherapy infusion. The patient asks what to do at home to
reduce complications from treatment-related
immunosuppression and oral mucosal irritation.
Question Stem:
Which discharge instructions should the nurse include? Select
all that apply.
Answer Options:
A. Use a soft toothbrush and gentle mouth rinses
B. Report a temperature of 38°C (100.4°F) or higher
