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 and reports chills, sore throat, and malaise. The
temperature is 38.4°C (101.1°F), and the absolute neutrophil
count is 420/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Notify the oncology provider immediately and initiate the
facility’s febrile neutropenia protocol
B. Give acetaminophen and reassess the temperature in 4 hours
C. Encourage oral fluids and discharge if the patient feels better
D. Wait for the next laboratory result before taking action
Correct Answer:
A
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency
because the body cannot mount an adequate immune
response. Rapid action is needed to reduce the risk of sepsis.
The nurse should notify the provider and begin the established
protocol, which typically includes cultures, broad-spectrum
antibiotics, and protective precautions.
,Incorrect Option Analysis:
• B: Acetaminophen may mask fever and delay treatment;
the misconception is that fever alone is the problem, when
infection risk is the emergency.
• C: Oral fluids are not the priority; this is unsafe because the
patient may be entering sepsis.
• D: Waiting delays life-saving treatment and increases
patient safety risk.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Recognize Cues, Prioritize
Hypotheses, Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation; Safety
and Infection Control
Nursing Diagnosis Integration: Risk for infection related to
neutropenia secondary to chemotherapy
Expected Outcome: The patient will receive prompt evaluation
and antibiotics, remain hemodynamically stable, and show no
progression to sepsis.
Key Learning Objective: Recognize and respond rapidly to
febrile neutropenia.
, 2. SATA
Clinical Scenario:
A patient receiving external-beam radiation to the chest asks
how to care for the skin in the treatment area.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area with lukewarm water and a mild soap
B. Apply perfume, deodorant, or alcohol-based lotion to the
area
C. Wear loose, soft cotton clothing over the treatment site
D. Use a heating pad if the skin feels sore
E. Avoid scrubbing or rubbing the treatment field
F. Expose the treatment area to sunlight to “dry it out”
Correct Answers:
A, C, E
Detailed Rationale:
Radiation damages skin integrity and increases sensitivity.
Gentle cleansing, loose clothing, and avoiding friction help
protect the skin barrier and reduce irritation.
Incorrect Option Analysis:
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 and reports chills, sore throat, and malaise. The
temperature is 38.4°C (101.1°F), and the absolute neutrophil
count is 420/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Notify the oncology provider immediately and initiate the
facility’s febrile neutropenia protocol
B. Give acetaminophen and reassess the temperature in 4 hours
C. Encourage oral fluids and discharge if the patient feels better
D. Wait for the next laboratory result before taking action
Correct Answer:
A
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency
because the body cannot mount an adequate immune
response. Rapid action is needed to reduce the risk of sepsis.
The nurse should notify the provider and begin the established
protocol, which typically includes cultures, broad-spectrum
antibiotics, and protective precautions.
,Incorrect Option Analysis:
• B: Acetaminophen may mask fever and delay treatment;
the misconception is that fever alone is the problem, when
infection risk is the emergency.
• C: Oral fluids are not the priority; this is unsafe because the
patient may be entering sepsis.
• D: Waiting delays life-saving treatment and increases
patient safety risk.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Recognize Cues, Prioritize
Hypotheses, Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation; Safety
and Infection Control
Nursing Diagnosis Integration: Risk for infection related to
neutropenia secondary to chemotherapy
Expected Outcome: The patient will receive prompt evaluation
and antibiotics, remain hemodynamically stable, and show no
progression to sepsis.
Key Learning Objective: Recognize and respond rapidly to
febrile neutropenia.
, 2. SATA
Clinical Scenario:
A patient receiving external-beam radiation to the chest asks
how to care for the skin in the treatment area.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area with lukewarm water and a mild soap
B. Apply perfume, deodorant, or alcohol-based lotion to the
area
C. Wear loose, soft cotton clothing over the treatment site
D. Use a heating pad if the skin feels sore
E. Avoid scrubbing or rubbing the treatment field
F. Expose the treatment area to sunlight to “dry it out”
Correct Answers:
A, C, E
Detailed Rationale:
Radiation damages skin integrity and increases sensitivity.
Gentle cleansing, loose clothing, and avoiding friction help
protect the skin barrier and reduce irritation.
Incorrect Option Analysis:
