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 with acute myelogenous leukemia is 7 days post-
chemotherapy. The patient has a temperature of 38.4°C
(101.1°F), chills, and an absolute neutrophil count (ANC) of
600/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Offer acetaminophen and recheck the temperature in 2
hours.
B. Notify the provider and activate the facility febrile
neutropenia protocol.
C. Encourage ambulation to improve circulation.
D. Obtain a rectal temperature to confirm fever.
Correct answer:
B
Detailed rationale:
Fever with neutropenia is an oncologic emergency because the
patient may deteriorate rapidly from sepsis. The nurse should
initiate the urgent response pathway, notify the provider, and
prepare for cultures and empiric antibiotics per protocol.
,Incorrect option analysis:
A. Incorrect because antipyretics may mask worsening infection
and delay urgent treatment.
C. Incorrect because ambulation does not address the infection
risk and may worsen instability.
D. Incorrect because rectal temperatures increase infection and
bleeding risk in neutropenic patients.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty level: Difficult
Bloom’s cognitive level: Analyze
NCLEX client needs category: Safety and Infection Control;
Physiological Adaptation
Nursing diagnosis integration:
Priority diagnosis: Risk for infection
Related factors: Myelosuppression secondary to chemotherapy
Risk indicators: Fever, ANC 600/mm³, chills
Expected outcome:
The patient receives cultures and empiric therapy promptly, and
signs of sepsis do not develop.
Key learning objective:
Prioritize urgent nursing actions for febrile neutropenia.
, 2) SATA — Cancer Care
Clinical scenario:
A patient receiving cyclophosphamide asks how to reduce
complications at home between treatments.
Question stem:
Which statements indicate correct understanding? Select all
that apply.
Answer options:
A. “I will use a soft-bristled toothbrush.”
B. “I should report a temperature of 38°C (100.4°F) or higher.”
C. “I can take aspirin for headaches.”
D. “I will avoid crowds and sick contacts when my counts are
low.”
E. “I should use a rectal suppository for constipation.”
Correct answers:
A, B, D
Detailed rationale:
These actions reduce mucosal trauma and infection exposure
during periods of myelosuppression.
Incorrect option analysis:
C. Incorrect because aspirin increases bleeding risk when
platelet counts may be reduced.
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 with acute myelogenous leukemia is 7 days post-
chemotherapy. The patient has a temperature of 38.4°C
(101.1°F), chills, and an absolute neutrophil count (ANC) of
600/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Offer acetaminophen and recheck the temperature in 2
hours.
B. Notify the provider and activate the facility febrile
neutropenia protocol.
C. Encourage ambulation to improve circulation.
D. Obtain a rectal temperature to confirm fever.
Correct answer:
B
Detailed rationale:
Fever with neutropenia is an oncologic emergency because the
patient may deteriorate rapidly from sepsis. The nurse should
initiate the urgent response pathway, notify the provider, and
prepare for cultures and empiric antibiotics per protocol.
,Incorrect option analysis:
A. Incorrect because antipyretics may mask worsening infection
and delay urgent treatment.
C. Incorrect because ambulation does not address the infection
risk and may worsen instability.
D. Incorrect because rectal temperatures increase infection and
bleeding risk in neutropenic patients.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty level: Difficult
Bloom’s cognitive level: Analyze
NCLEX client needs category: Safety and Infection Control;
Physiological Adaptation
Nursing diagnosis integration:
Priority diagnosis: Risk for infection
Related factors: Myelosuppression secondary to chemotherapy
Risk indicators: Fever, ANC 600/mm³, chills
Expected outcome:
The patient receives cultures and empiric therapy promptly, and
signs of sepsis do not develop.
Key learning objective:
Prioritize urgent nursing actions for febrile neutropenia.
, 2) SATA — Cancer Care
Clinical scenario:
A patient receiving cyclophosphamide asks how to reduce
complications at home between treatments.
Question stem:
Which statements indicate correct understanding? Select all
that apply.
Answer options:
A. “I will use a soft-bristled toothbrush.”
B. “I should report a temperature of 38°C (100.4°F) or higher.”
C. “I can take aspirin for headaches.”
D. “I will avoid crowds and sick contacts when my counts are
low.”
E. “I should use a rectal suppository for constipation.”
Correct answers:
A, B, D
Detailed rationale:
These actions reduce mucosal trauma and infection exposure
during periods of myelosuppression.
Incorrect option analysis:
C. Incorrect because aspirin increases bleeding risk when
platelet counts may be reduced.
