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 58-year-old receiving cytotoxic
chemotherapy reports chills and feels “extremely weak.” The
temperature is 38.4°C (101.1°F), heart rate is 108/min, and the
absolute neutrophil count is 700/mm³.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Administer acetaminophen and recheck temperature in 1
hour
B. Place the client on airborne precautions
C. Notify the provider and prepare to obtain blood cultures
before antibiotics
D. Encourage the client to increase oral fluids and rest at home
Correct Answer: C
Detailed Rationale:
This client has febrile neutropenia, a medical emergency in
oncology because infection can progress rapidly when
neutrophils are low. The nurse should notify the provider
promptly and prepare for cultures and rapid broad-spectrum
antibiotics as ordered. Patient safety depends on early
recognition and treatment.
Incorrect Option Analysis:
, • A: Acetaminophen may mask fever and delay treatment.
Misconception: treating the symptom first is enough.
• B: Airborne precautions are not indicated for neutropenia.
Misconception: all infection risks require the same
isolation.
• D: Home rest is unsafe with fever and neutropenia.
Misconception: mild symptoms can be managed later.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Myelosuppression, neutropenia, invasive
cancer therapy
Expected Outcome: The client receives timely antimicrobial
treatment with no progression to sepsis.
Key Learning Objective: Prioritize lifesaving nursing actions in
febrile neutropenia.
2) SATA — Cancer Care
, Clinical Scenario: A client is starting outpatient chemotherapy
and asks what to do at home to reduce complications.
Question Stem: Which instructions should the nurse include?
Select all that apply.
Answer Options:
A. Check the temperature daily and report fever promptly
B. Use a soft-bristled toothbrush and gentle oral care
C. Take over-the-counter ibuprofen routinely for all body aches
D. Avoid contact with people who are sick
E. Take prescribed antiemetics before nausea becomes severe
Correct Answers: A, B, D, E
Detailed Rationale:
These are standard supportive care measures for
chemotherapy-related immunosuppression, mucosal injury, and
nausea prevention. Early fever reporting is essential because
infection may be subtle but dangerous.
Incorrect Option Analysis:
• C: Routine ibuprofen can increase bleeding risk and may
mask fever. Misconception: all pain relievers are equally
safe.
Nursing Process Linkage: Planning
NCJMM Competencies: Generate Solutions; Take Action
Difficulty Level: Moderate
Bloom’s Level: Apply
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 58-year-old receiving cytotoxic
chemotherapy reports chills and feels “extremely weak.” The
temperature is 38.4°C (101.1°F), heart rate is 108/min, and the
absolute neutrophil count is 700/mm³.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Administer acetaminophen and recheck temperature in 1
hour
B. Place the client on airborne precautions
C. Notify the provider and prepare to obtain blood cultures
before antibiotics
D. Encourage the client to increase oral fluids and rest at home
Correct Answer: C
Detailed Rationale:
This client has febrile neutropenia, a medical emergency in
oncology because infection can progress rapidly when
neutrophils are low. The nurse should notify the provider
promptly and prepare for cultures and rapid broad-spectrum
antibiotics as ordered. Patient safety depends on early
recognition and treatment.
Incorrect Option Analysis:
, • A: Acetaminophen may mask fever and delay treatment.
Misconception: treating the symptom first is enough.
• B: Airborne precautions are not indicated for neutropenia.
Misconception: all infection risks require the same
isolation.
• D: Home rest is unsafe with fever and neutropenia.
Misconception: mild symptoms can be managed later.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Myelosuppression, neutropenia, invasive
cancer therapy
Expected Outcome: The client receives timely antimicrobial
treatment with no progression to sepsis.
Key Learning Objective: Prioritize lifesaving nursing actions in
febrile neutropenia.
2) SATA — Cancer Care
, Clinical Scenario: A client is starting outpatient chemotherapy
and asks what to do at home to reduce complications.
Question Stem: Which instructions should the nurse include?
Select all that apply.
Answer Options:
A. Check the temperature daily and report fever promptly
B. Use a soft-bristled toothbrush and gentle oral care
C. Take over-the-counter ibuprofen routinely for all body aches
D. Avoid contact with people who are sick
E. Take prescribed antiemetics before nausea becomes severe
Correct Answers: A, B, D, E
Detailed Rationale:
These are standard supportive care measures for
chemotherapy-related immunosuppression, mucosal injury, and
nausea prevention. Early fever reporting is essential because
infection may be subtle but dangerous.
Incorrect Option Analysis:
• C: Routine ibuprofen can increase bleeding risk and may
mask fever. Misconception: all pain relievers are equally
safe.
Nursing Process Linkage: Planning
NCJMM Competencies: Generate Solutions; Take Action
Difficulty Level: Moderate
Bloom’s Level: Apply
