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 62-year-old client receiving the second cycle
of chemotherapy reports a temperature of 38.4°C (101.1°F),
sore throat, and fatigue. The ANC is 400/mm³.
Question stem: What is the nurse’s priority action?
Options:
A. Initiate neutropenic precautions and notify the oncology
provider immediately
B. Encourage increased oral fluid intake and reassess in 4 hours
C. Give an antipyretic and apply cool compresses
D. Teach the client to avoid spicy foods until the sore throat
resolves
Correct answer: A
Rationale: Fever with severe neutropenia is an oncologic
emergency. The priority is infection prevention and rapid
escalation for urgent treatment, including cultures and broad-
spectrum antibiotics per protocol.
Incorrect options:
B: Hydration is helpful, but this delays treatment of a possible
life-threatening infection.
C: Antipyretics may mask fever and delay recognition; they do
not address the cause.
,D: Diet advice is not the priority when neutropenic fever is
suspected.
Nursing process linkage: Implementation
NCJMM: Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration: Risk for infection related to
chemotherapy-induced neutropenia
Expected outcome: Client will receive urgent infection
management with no delay in therapy initiation.
Key learning objective: Identify and respond to neutropenic
fever as a priority cancer-care emergency.
2) SATA — Cancer Care
Clinical scenario: A client is receiving chemotherapy and
reports mouth soreness, nausea, and decreased appetite.
Question stem: Which nursing interventions should be included
in the care plan? Select all that apply.
Options:
A. Use a soft-bristled toothbrush
B. Encourage alcohol-based mouthwash
C. Offer small, frequent meals
, D. Report a temperature of 38°C (100.4°F) or higher
E. Use rectal thermometers for accurate readings
Correct answers: A, C, D
Rationale: Soft oral care reduces mucosal injury; small frequent
meals help nausea and anorexia; fever must be reported
promptly in immunosuppressed clients.
Incorrect options:
B: Alcohol-based mouthwash can worsen mucositis.
E: Rectal temperatures can injure fragile tissue and increase
infection risk.
Nursing process linkage: Planning / Implementation
NCJMM: Recognize Cues, Generate Solutions, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Impaired oral mucous
membrane and Risk for infection
Expected outcome: Client will maintain intact oral mucosa and
remain free from infection signs.
Key learning objective: Select supportive chemotherapy care
measures that reduce mucosal injury and infection risk.
3) NGN Case Study — Cancer Care / Radiation Therapy
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 62-year-old client receiving the second cycle
of chemotherapy reports a temperature of 38.4°C (101.1°F),
sore throat, and fatigue. The ANC is 400/mm³.
Question stem: What is the nurse’s priority action?
Options:
A. Initiate neutropenic precautions and notify the oncology
provider immediately
B. Encourage increased oral fluid intake and reassess in 4 hours
C. Give an antipyretic and apply cool compresses
D. Teach the client to avoid spicy foods until the sore throat
resolves
Correct answer: A
Rationale: Fever with severe neutropenia is an oncologic
emergency. The priority is infection prevention and rapid
escalation for urgent treatment, including cultures and broad-
spectrum antibiotics per protocol.
Incorrect options:
B: Hydration is helpful, but this delays treatment of a possible
life-threatening infection.
C: Antipyretics may mask fever and delay recognition; they do
not address the cause.
,D: Diet advice is not the priority when neutropenic fever is
suspected.
Nursing process linkage: Implementation
NCJMM: Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration: Risk for infection related to
chemotherapy-induced neutropenia
Expected outcome: Client will receive urgent infection
management with no delay in therapy initiation.
Key learning objective: Identify and respond to neutropenic
fever as a priority cancer-care emergency.
2) SATA — Cancer Care
Clinical scenario: A client is receiving chemotherapy and
reports mouth soreness, nausea, and decreased appetite.
Question stem: Which nursing interventions should be included
in the care plan? Select all that apply.
Options:
A. Use a soft-bristled toothbrush
B. Encourage alcohol-based mouthwash
C. Offer small, frequent meals
, D. Report a temperature of 38°C (100.4°F) or higher
E. Use rectal thermometers for accurate readings
Correct answers: A, C, D
Rationale: Soft oral care reduces mucosal injury; small frequent
meals help nausea and anorexia; fever must be reported
promptly in immunosuppressed clients.
Incorrect options:
B: Alcohol-based mouthwash can worsen mucositis.
E: Rectal temperatures can injure fragile tissue and increase
infection risk.
Nursing process linkage: Planning / Implementation
NCJMM: Recognize Cues, Generate Solutions, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Impaired oral mucous
membrane and Risk for infection
Expected outcome: Client will maintain intact oral mucosa and
remain free from infection signs.
Key learning objective: Select supportive chemotherapy care
measures that reduce mucosal injury and infection risk.
3) NGN Case Study — Cancer Care / Radiation Therapy
