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: Febrile Neutropenia
Clinical scenario:
A 62-year-old patient is on day 8 after chemotherapy for
lymphoma. The patient reports chills and weakness. Vitals are T
38.4°C (101.1°F), HR 112, BP 104/66, RR 20. The absolute
neutrophil count from this morning is 700/mm³.
Question stem:
Which nursing action is the priority?
Answer options:
A. Encourage oral fluids and recheck temperature in 4 hours
B. Place the patient on protective precautions and notify the
provider immediately
C. Administer acetaminophen and document the fever
D. Reassure the patient that fever is expected after
chemotherapy
Correct answer:
B
Detailed rationale:
A fever in a patient with chemotherapy-related neutropenia is a
high-risk finding for infection. The priority is to protect the
patient and escalate care immediately so treatment can begin
without delay. NCI highlights infection/neutropenia as a major
treatment complication and stresses prompt reporting of
concerning symptoms.
,Incorrect option analysis:
A: Delays treatment. Oral fluids are supportive but not the first
priority.
C: Masks the fever and postpones evaluation.
D: Incorrect and unsafe; fever in neutropenia is not expected to
be ignored.
Nursing process linkage: Implementation
NCJMM: Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation / Safety and
Infection Control
Nursing diagnosis integration: Priority diagnosis: Risk for
infection related to immunosuppression/neutropenia. Risk
factors: chemotherapy, low ANC, chills, fever.
Expected outcome: The patient receives immediate evaluation
and infection-prevention measures, with temperature and
hemodynamics stabilized.
Key learning objective: Identify febrile neutropenia as an
urgent oncology safety problem.
2) SATA — Cancer Care: Immunotherapy Toxicity
, Clinical scenario:
A patient receiving immune checkpoint therapy returns to clinic
3 weeks after treatment and reports new symptoms.
Question stem:
Which findings should the nurse instruct the patient to report
promptly as possible immune-related adverse effects?
Select all that apply.
Answer options:
A. New watery diarrhea
B. New rash or itching
C. New cough or shortness of breath
D. Mild hair thinning
E. Occasional dry mouth only
Correct answers:
A, B, C
Detailed rationale:
Immunotherapy can trigger the immune system to attack
healthy tissue, so new GI, skin, or pulmonary symptoms can be
clinically important. Diarrhea, rash, and cough/shortness of
breath are classic “report now” findings because they may
represent immune-mediated toxicity.
Incorrect option analysis:
D: Hair thinning is not the most urgent immune-related warning
sign here.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care: Febrile Neutropenia
Clinical scenario:
A 62-year-old patient is on day 8 after chemotherapy for
lymphoma. The patient reports chills and weakness. Vitals are T
38.4°C (101.1°F), HR 112, BP 104/66, RR 20. The absolute
neutrophil count from this morning is 700/mm³.
Question stem:
Which nursing action is the priority?
Answer options:
A. Encourage oral fluids and recheck temperature in 4 hours
B. Place the patient on protective precautions and notify the
provider immediately
C. Administer acetaminophen and document the fever
D. Reassure the patient that fever is expected after
chemotherapy
Correct answer:
B
Detailed rationale:
A fever in a patient with chemotherapy-related neutropenia is a
high-risk finding for infection. The priority is to protect the
patient and escalate care immediately so treatment can begin
without delay. NCI highlights infection/neutropenia as a major
treatment complication and stresses prompt reporting of
concerning symptoms.
,Incorrect option analysis:
A: Delays treatment. Oral fluids are supportive but not the first
priority.
C: Masks the fever and postpones evaluation.
D: Incorrect and unsafe; fever in neutropenia is not expected to
be ignored.
Nursing process linkage: Implementation
NCJMM: Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation / Safety and
Infection Control
Nursing diagnosis integration: Priority diagnosis: Risk for
infection related to immunosuppression/neutropenia. Risk
factors: chemotherapy, low ANC, chills, fever.
Expected outcome: The patient receives immediate evaluation
and infection-prevention measures, with temperature and
hemodynamics stabilized.
Key learning objective: Identify febrile neutropenia as an
urgent oncology safety problem.
2) SATA — Cancer Care: Immunotherapy Toxicity
, Clinical scenario:
A patient receiving immune checkpoint therapy returns to clinic
3 weeks after treatment and reports new symptoms.
Question stem:
Which findings should the nurse instruct the patient to report
promptly as possible immune-related adverse effects?
Select all that apply.
Answer options:
A. New watery diarrhea
B. New rash or itching
C. New cough or shortness of breath
D. Mild hair thinning
E. Occasional dry mouth only
Correct answers:
A, B, C
Detailed rationale:
Immunotherapy can trigger the immune system to attack
healthy tissue, so new GI, skin, or pulmonary symptoms can be
clinically important. Diarrhea, rash, and cough/shortness of
breath are classic “report now” findings because they may
represent immune-mediated toxicity.
Incorrect option analysis:
D: Hair thinning is not the most urgent immune-related warning
sign here.
