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 chemotherapy phones the clinic and reports
a temperature of 38.3°C (100.9°F), sore throat, and an absolute
neutrophil count of 450/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Tell the patient to take acetaminophen and rest at home.
B. Notify the provider and prepare for blood cultures and
empiric antibiotics.
C. Encourage oral fluids and schedule the next lab draw
tomorrow.
D. Apply warm blankets and reassess the temperature in 1 hour.
Correct Answer:
B
Detailed Rationale:
This is febrile neutropenia, a medical emergency in oncology.
The patient is at high risk for rapid sepsis, so the nurse must act
immediately to support timely culture collection and antibiotic
treatment.
Incorrect Option Analysis:
, • A: Masks a potentially serious infection and delays
treatment.
• C: Delays urgent intervention and does not address
infection risk.
• D: Treats the symptom, not the cause, and may delay
lifesaving care.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation;
Reduction of Risk Potential
Nursing Diagnosis Integration:
Priority Diagnosis: Risk for infection
Related Factors: Chemotherapy-induced neutropenia
Defining Characteristics: Fever, sore throat, ANC 450/mm³
Expected Outcome:
The patient receives cultures and empiric antibiotics promptly,
with no progression to sepsis.
, Key Learning Objective:
Identify and respond to febrile neutropenia as an oncologic
emergency.
2) SATA — Cancer Care
Clinical Scenario:
A patient receiving external beam radiation therapy 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 gently with lukewarm water and mild soap.
B. Apply a prescribed water-based moisturizer after treatment.
C. Expose the treatment area to direct sunlight to help it heal.
D. Avoid adhesive tape over the treated skin.
E. Use a heating pad if the skin feels irritated.
Correct Answers:
A, B, D
Detailed Rationale:
Radiation skin care focuses on gentle cleansing, protection
from trauma, and avoiding irritation. Water-based moisturizer
may be used if prescribed and timed appropriately.
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 chemotherapy phones the clinic and reports
a temperature of 38.3°C (100.9°F), sore throat, and an absolute
neutrophil count of 450/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Tell the patient to take acetaminophen and rest at home.
B. Notify the provider and prepare for blood cultures and
empiric antibiotics.
C. Encourage oral fluids and schedule the next lab draw
tomorrow.
D. Apply warm blankets and reassess the temperature in 1 hour.
Correct Answer:
B
Detailed Rationale:
This is febrile neutropenia, a medical emergency in oncology.
The patient is at high risk for rapid sepsis, so the nurse must act
immediately to support timely culture collection and antibiotic
treatment.
Incorrect Option Analysis:
, • A: Masks a potentially serious infection and delays
treatment.
• C: Delays urgent intervention and does not address
infection risk.
• D: Treats the symptom, not the cause, and may delay
lifesaving care.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation;
Reduction of Risk Potential
Nursing Diagnosis Integration:
Priority Diagnosis: Risk for infection
Related Factors: Chemotherapy-induced neutropenia
Defining Characteristics: Fever, sore throat, ANC 450/mm³
Expected Outcome:
The patient receives cultures and empiric antibiotics promptly,
with no progression to sepsis.
, Key Learning Objective:
Identify and respond to febrile neutropenia as an oncologic
emergency.
2) SATA — Cancer Care
Clinical Scenario:
A patient receiving external beam radiation therapy 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 gently with lukewarm water and mild soap.
B. Apply a prescribed water-based moisturizer after treatment.
C. Expose the treatment area to direct sunlight to help it heal.
D. Avoid adhesive tape over the treated skin.
E. Use a heating pad if the skin feels irritated.
Correct Answers:
A, B, D
Detailed Rationale:
Radiation skin care focuses on gentle cleansing, protection
from trauma, and avoiding irritation. Water-based moisturizer
may be used if prescribed and timed appropriately.
