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 with breast cancer is receiving cycle 2 of
chemotherapy. The patient reports chills, feels weak, and has an
oral temperature of 38.4°C (101.1°F). The absolute neutrophil
count is 450/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 1 hour.
B. Place the patient on protective precautions and notify the
provider immediately.
C. Encourage oral fluids and rest.
D. Delay the next chemotherapy dose until the patient feels
better.
Correct answer:
B
Detailed rationale:
This patient has febrile neutropenia, which is an emergency
because infection can progress rapidly when neutrophils are
severely low. The nurse should initiate infection precautions
,and notify the provider immediately so cultures and prompt
antibiotics can be started.
Incorrect option analysis:
• A: Fever-reducing medication may mask worsening
infection. Common misconception: treating the symptom
first instead of the cause.
• C: Fluids and rest are supportive but not the priority.
• D: Delaying chemotherapy may be part of the plan later,
but it does not address the immediate risk.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty:
Difficult
Bloom’s level:
Analyze
NCLEX client needs category:
Physiological Adaptation
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for infection
Risk factors: Chemotherapy, neutropenia, fever
, Expected outcome:
The patient remains hemodynamically stable and receives
prompt treatment for suspected infection.
Key learning objective:
Prioritize urgent interventions for neutropenic fever.
2) SATA
Clinical scenario:
A patient is receiving external beam radiation therapy to the
chest wall. The skin in the treatment area is pink, dry, and
tender.
Question stem:
Which teaching points should the nurse include? Select all that
apply.
Answer options:
A. Wash the area with lukewarm water and mild soap.
B. Apply lotion immediately before treatment to reduce
dryness.
C. Protect the area from sun exposure.
D. Wear loose, soft clothing over the treatment site.
E. Use adhesive tape directly on the irradiated skin when
possible.
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 with breast cancer is receiving cycle 2 of
chemotherapy. The patient reports chills, feels weak, and has an
oral temperature of 38.4°C (101.1°F). The absolute neutrophil
count is 450/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 1 hour.
B. Place the patient on protective precautions and notify the
provider immediately.
C. Encourage oral fluids and rest.
D. Delay the next chemotherapy dose until the patient feels
better.
Correct answer:
B
Detailed rationale:
This patient has febrile neutropenia, which is an emergency
because infection can progress rapidly when neutrophils are
severely low. The nurse should initiate infection precautions
,and notify the provider immediately so cultures and prompt
antibiotics can be started.
Incorrect option analysis:
• A: Fever-reducing medication may mask worsening
infection. Common misconception: treating the symptom
first instead of the cause.
• C: Fluids and rest are supportive but not the priority.
• D: Delaying chemotherapy may be part of the plan later,
but it does not address the immediate risk.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty:
Difficult
Bloom’s level:
Analyze
NCLEX client needs category:
Physiological Adaptation
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for infection
Risk factors: Chemotherapy, neutropenia, fever
, Expected outcome:
The patient remains hemodynamically stable and receives
prompt treatment for suspected infection.
Key learning objective:
Prioritize urgent interventions for neutropenic fever.
2) SATA
Clinical scenario:
A patient is receiving external beam radiation therapy to the
chest wall. The skin in the treatment area is pink, dry, and
tender.
Question stem:
Which teaching points should the nurse include? Select all that
apply.
Answer options:
A. Wash the area with lukewarm water and mild soap.
B. Apply lotion immediately before treatment to reduce
dryness.
C. Protect the area from sun exposure.
D. Wear loose, soft clothing over the treatment site.
E. Use adhesive tape directly on the irradiated skin when
possible.
