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 patient receiving the second cycle of chemotherapy reports
chills and a sore throat. The temperature is 38.4°C (101.1°F),
the ANC is 350/mm³, and the mucous membranes are dry.
Question Stem:
Which prescription should the nurse anticipate as the priority?
Answer Options:
A. Encourage increased oral fluids and reassess in 4 hours
B. Administer prescribed IV broad-spectrum antibiotics after
blood cultures are obtained
C. Give an oral antipyretic and discharge home
D. Place the patient on contact precautions only
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency in
oncology care. The nurse should anticipate rapid cultures and
prompt IV broad-spectrum antibiotics because infection can
progress quickly when immune defenses are suppressed. The
dry mucosa also suggests a breakdown in protective barriers,
increasing infection risk.
,Incorrect Option Analysis:
A. Hydration is helpful, but it does not address the immediate
risk of sepsis.
C. Fever in a neutropenic patient is not managed as a simple
outpatient issue.
D. Contact precautions alone do not treat the underlying
infection risk.
Nursing Process Linkage:
Implementation
NCJMM Competency:
Recognize Cues; Take Action
Difficulty:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Nursing Diagnosis Integration:
Priority nursing diagnosis: Risk for infection
Risk factors: chemotherapy-induced neutropenia, mucosal
breakdown, fever
Expected Outcome:
The patient will receive prompt cultures and IV antibiotics
, within the expected treatment window, with no progression to
shock.
Key Learning Objective:
Prioritize urgent care for neutropenic fever and apply oncology
safety principles.
2) SATA
Clinical Scenario:
A patient is receiving external beam radiation therapy to the
chest wall for breast cancer. The patient asks how to care for
the skin in the treatment area.
Question Stem:
Which teaching points should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap
B. Apply heating pads to relieve discomfort
C. Wear loose, soft clothing over the area
D. Use adhesive tape on the irradiated skin if the dressing
loosens
E. Protect the treatment area from sun exposure
Correct Answers:
A, C, E
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 patient receiving the second cycle of chemotherapy reports
chills and a sore throat. The temperature is 38.4°C (101.1°F),
the ANC is 350/mm³, and the mucous membranes are dry.
Question Stem:
Which prescription should the nurse anticipate as the priority?
Answer Options:
A. Encourage increased oral fluids and reassess in 4 hours
B. Administer prescribed IV broad-spectrum antibiotics after
blood cultures are obtained
C. Give an oral antipyretic and discharge home
D. Place the patient on contact precautions only
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency in
oncology care. The nurse should anticipate rapid cultures and
prompt IV broad-spectrum antibiotics because infection can
progress quickly when immune defenses are suppressed. The
dry mucosa also suggests a breakdown in protective barriers,
increasing infection risk.
,Incorrect Option Analysis:
A. Hydration is helpful, but it does not address the immediate
risk of sepsis.
C. Fever in a neutropenic patient is not managed as a simple
outpatient issue.
D. Contact precautions alone do not treat the underlying
infection risk.
Nursing Process Linkage:
Implementation
NCJMM Competency:
Recognize Cues; Take Action
Difficulty:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Nursing Diagnosis Integration:
Priority nursing diagnosis: Risk for infection
Risk factors: chemotherapy-induced neutropenia, mucosal
breakdown, fever
Expected Outcome:
The patient will receive prompt cultures and IV antibiotics
, within the expected treatment window, with no progression to
shock.
Key Learning Objective:
Prioritize urgent care for neutropenic fever and apply oncology
safety principles.
2) SATA
Clinical Scenario:
A patient is receiving external beam radiation therapy to the
chest wall for breast cancer. The patient asks how to care for
the skin in the treatment area.
Question Stem:
Which teaching points should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with lukewarm water and mild soap
B. Apply heating pads to relieve discomfort
C. Wear loose, soft clothing over the area
D. Use adhesive tape on the irradiated skin if the dressing
loosens
E. Protect the treatment area from sun exposure
Correct Answers:
A, C, E
