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 62-year-old patient receiving combination chemotherapy
reports chills and a sore throat. The temperature is 38.4°C
(101.1°F), ANC is 600/mm³, and the oral mucosa is inflamed.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage extra oral fluids and reassess in 2 hours
B. Notify the provider immediately and prepare for neutropenic
fever management
C. Give acetaminophen and apply cool compresses
D. Teach the patient to increase fresh fruits and salads
Correct Answer:
B
Detailed Rationale:
A fever in a patient with severe neutropenia is a medical
emergency because infection can progress rapidly without a
strong inflammatory response. The nurse should notify the
provider immediately and prepare for urgent evaluation and
likely broad-spectrum antibiotics.
Incorrect Option Analysis:
, • A: Fluids are helpful, but this delays urgent action.
• C: Acetaminophen may mask worsening infection and does
not address the cause.
• D: Raw fruits and salads increase exposure to pathogens
and are inappropriate during neutropenia.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Priority Nursing Diagnosis: Risk for Infection
Related Factors: Immunosuppression, low ANC, mucosal
breakdown
Risk Factors: Chemotherapy, neutropenia, mucositis
Expected Outcome: The provider is notified promptly and
treatment for suspected neutropenic fever begins without
delay.
Key Learning Objective: Recognize urgent infection risk in
immunocompromised cancer patients.
2) SATA
, Clinical Scenario:
A patient receiving external beam radiation to the chest asks
how to care for the treated skin.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap
B. Apply petroleum jelly immediately before treatment
C. Avoid direct sunlight on the treated area
D. Wear loose, soft clothing over the site
E. Use adhesive tape directly on the marked skin
Correct Answers:
A, C, D
Detailed Rationale:
Radiation skin care focuses on reducing irritation and protecting
fragile tissue. Gentle cleansing, sun protection, and loose
clothing reduce trauma to the area.
Incorrect Option Analysis:
• B: Oily products can interfere with radiation delivery unless
specifically approved.
• E: Adhesive tape may damage sensitive irradiated skin.
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 62-year-old patient receiving combination chemotherapy
reports chills and a sore throat. The temperature is 38.4°C
(101.1°F), ANC is 600/mm³, and the oral mucosa is inflamed.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage extra oral fluids and reassess in 2 hours
B. Notify the provider immediately and prepare for neutropenic
fever management
C. Give acetaminophen and apply cool compresses
D. Teach the patient to increase fresh fruits and salads
Correct Answer:
B
Detailed Rationale:
A fever in a patient with severe neutropenia is a medical
emergency because infection can progress rapidly without a
strong inflammatory response. The nurse should notify the
provider immediately and prepare for urgent evaluation and
likely broad-spectrum antibiotics.
Incorrect Option Analysis:
, • A: Fluids are helpful, but this delays urgent action.
• C: Acetaminophen may mask worsening infection and does
not address the cause.
• D: Raw fruits and salads increase exposure to pathogens
and are inappropriate during neutropenia.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Priority Nursing Diagnosis: Risk for Infection
Related Factors: Immunosuppression, low ANC, mucosal
breakdown
Risk Factors: Chemotherapy, neutropenia, mucositis
Expected Outcome: The provider is notified promptly and
treatment for suspected neutropenic fever begins without
delay.
Key Learning Objective: Recognize urgent infection risk in
immunocompromised cancer patients.
2) SATA
, Clinical Scenario:
A patient receiving external beam radiation to the chest asks
how to care for the treated skin.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap
B. Apply petroleum jelly immediately before treatment
C. Avoid direct sunlight on the treated area
D. Wear loose, soft clothing over the site
E. Use adhesive tape directly on the marked skin
Correct Answers:
A, C, D
Detailed Rationale:
Radiation skin care focuses on reducing irritation and protecting
fragile tissue. Gentle cleansing, sun protection, and loose
clothing reduce trauma to the area.
Incorrect Option Analysis:
• B: Oily products can interfere with radiation delivery unless
specifically approved.
• E: Adhesive tape may damage sensitive irradiated skin.
