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 patient receiving cycle 2 of chemotherapy
reports chills and malaise. The temperature is 38.5°C (101.3°F),
heart rate is 112/min, and the absolute neutrophil count is
400/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 4 hours
B. Place the patient on neutropenic precautions only
C. Obtain cultures and prepare to start broad-spectrum IV
antibiotics
D. Encourage oral fluids and rest
Correct answer: C
Detailed rationale: Fever with severe neutropenia is a medical
emergency because infection can progress rapidly to sepsis. The
nurse should follow the facility’s febrile neutropenia protocol:
obtain ordered cultures promptly and initiate prescribed IV
antibiotics without delay.
Incorrect option analysis:
• A: Masks the fever and delays treatment; it does not
address the likely infection source.
• B: Isolation alone is insufficient once fever is present.
, • D: Supportive care is helpful, but not the priority in
suspected neutropenic infection.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX Client Needs: Physiological Adaptation; Reduction of
Risk Potential
Nursing diagnosis integration:
• Priority nursing diagnosis: Risk for infection
• Risk factors: Chemotherapy-induced neutropenia
• Expected outcome: Antibiotics are initiated promptly, and
the patient remains hemodynamically stable without
progression to sepsis.
Key learning objective: Prioritize immediate intervention
for febrile neutropenia.
2) SATA — Cancer Care
Clinical scenario: A patient beginning outpatient chemotherapy
asks what to do at home to stay safe between treatments.
Question stem: Which instructions should the nurse include?
Select all that apply.
, Answer options:
A. Check the temperature daily and report fever promptly
B. Use a soft toothbrush and electric razor
C. Take over-the-counter ibuprofen for any fever
D. Increase fluid intake unless restricted
E. Use a rectal suppository if constipation occurs
F. Avoid live vaccines unless the oncology team approves
Correct answers: A, B, D, F
Detailed rationale: Chemotherapy commonly suppresses bone
marrow and increases infection and bleeding risk. Fever
reporting, gentle oral care, hydration, and avoiding live vaccines
support safety during treatment.
Incorrect option analysis:
• C: NSAIDs can increase bleeding risk and may mask
infection.
• E: Rectal products can injure mucosa and increase
infection risk in neutropenic patients.
Nursing process linkage: Planning / Patient education
NCJMM competencies: Generate Solutions, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX Client Needs: Management of Care; Safety and 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
Clinical scenario: A patient receiving cycle 2 of chemotherapy
reports chills and malaise. The temperature is 38.5°C (101.3°F),
heart rate is 112/min, and the absolute neutrophil count is
400/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 4 hours
B. Place the patient on neutropenic precautions only
C. Obtain cultures and prepare to start broad-spectrum IV
antibiotics
D. Encourage oral fluids and rest
Correct answer: C
Detailed rationale: Fever with severe neutropenia is a medical
emergency because infection can progress rapidly to sepsis. The
nurse should follow the facility’s febrile neutropenia protocol:
obtain ordered cultures promptly and initiate prescribed IV
antibiotics without delay.
Incorrect option analysis:
• A: Masks the fever and delays treatment; it does not
address the likely infection source.
• B: Isolation alone is insufficient once fever is present.
, • D: Supportive care is helpful, but not the priority in
suspected neutropenic infection.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX Client Needs: Physiological Adaptation; Reduction of
Risk Potential
Nursing diagnosis integration:
• Priority nursing diagnosis: Risk for infection
• Risk factors: Chemotherapy-induced neutropenia
• Expected outcome: Antibiotics are initiated promptly, and
the patient remains hemodynamically stable without
progression to sepsis.
Key learning objective: Prioritize immediate intervention
for febrile neutropenia.
2) SATA — Cancer Care
Clinical scenario: A patient beginning outpatient chemotherapy
asks what to do at home to stay safe between treatments.
Question stem: Which instructions should the nurse include?
Select all that apply.
, Answer options:
A. Check the temperature daily and report fever promptly
B. Use a soft toothbrush and electric razor
C. Take over-the-counter ibuprofen for any fever
D. Increase fluid intake unless restricted
E. Use a rectal suppository if constipation occurs
F. Avoid live vaccines unless the oncology team approves
Correct answers: A, B, D, F
Detailed rationale: Chemotherapy commonly suppresses bone
marrow and increases infection and bleeding risk. Fever
reporting, gentle oral care, hydration, and avoiding live vaccines
support safety during treatment.
Incorrect option analysis:
• C: NSAIDs can increase bleeding risk and may mask
infection.
• E: Rectal products can injure mucosa and increase
infection risk in neutropenic patients.
Nursing process linkage: Planning / Patient education
NCJMM competencies: Generate Solutions, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX Client Needs: Management of Care; Safety and Infection
