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 — Febrile Neutropenia in Chemotherapy
Clinical Scenario:
A 58-year-old patient is receiving cycle 2 of chemotherapy for
lymphoma. The patient reports chills and sore throat. Vital signs
show temperature 38.5°C (101.3°F), heart rate 112/min, blood
pressure 104/62 mm Hg, and absolute neutrophil count (ANC)
400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Administer acetaminophen and reassess the temperature in
4 hours.
B. Place the patient on protective precautions and obtain blood
cultures as prescribed.
C. Encourage oral fluids and ambulation to reduce infection risk.
D. Notify the family that fever is expected during chemotherapy.
Correct Answer:
B
Detailed Rationale:
Fever with profound neutropenia is a medical emergency
because the patient may not be able to mount a normal
inflammatory response. The nurse should rapidly escalate care,
begin infection-control measures, and support prompt cultures
and empiric antibiotics per protocol.
,Incorrect Option Analysis:
• A: Incorrect because it delays urgent treatment and may
mask the severity of infection. Common misconception:
treating the symptom is enough.
• C: Incorrect because ambulation is not the priority and
may worsen instability.
• D: Incorrect because fever is not “expected” and requires
immediate action.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Priority Nursing Diagnosis: Risk for infection related to
neutropenia
Related Factors/Risk Factors: Bone marrow suppression, ANC
400/mm³, mucosal barrier breakdown
Expected Outcome: The patient will receive timely cultures and
antibiotics, and temperature will begin to trend down within 24
hours.
Key Learning Objective: Identify and prioritize life-threatening
infection in the immunocompromised patient.
, 2. SATA — Safe Oral Chemotherapy Teaching
Clinical Scenario:
A patient is being discharged on an oral chemotherapy agent
and asks how to handle the medication safely at home.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash hands after contact with body fluids.
B. Crush tablets if swallowing is difficult.
C. Keep the medication in its original container away from
children.
D. Report fever, uncontrolled vomiting, or severe diarrhea
promptly.
E. Double the next dose if one dose is missed.
Correct Answers:
A, C, D
Detailed Rationale:
Oral chemotherapy requires careful handling because drug
metabolites can be present in body fluids and because dosing
errors can cause toxicity. Safety teaching includes proper
storage, infection reporting, and follow-up for adverse effects.
Incorrect Option Analysis:
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1. MCQ — Febrile Neutropenia in Chemotherapy
Clinical Scenario:
A 58-year-old patient is receiving cycle 2 of chemotherapy for
lymphoma. The patient reports chills and sore throat. Vital signs
show temperature 38.5°C (101.3°F), heart rate 112/min, blood
pressure 104/62 mm Hg, and absolute neutrophil count (ANC)
400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Administer acetaminophen and reassess the temperature in
4 hours.
B. Place the patient on protective precautions and obtain blood
cultures as prescribed.
C. Encourage oral fluids and ambulation to reduce infection risk.
D. Notify the family that fever is expected during chemotherapy.
Correct Answer:
B
Detailed Rationale:
Fever with profound neutropenia is a medical emergency
because the patient may not be able to mount a normal
inflammatory response. The nurse should rapidly escalate care,
begin infection-control measures, and support prompt cultures
and empiric antibiotics per protocol.
,Incorrect Option Analysis:
• A: Incorrect because it delays urgent treatment and may
mask the severity of infection. Common misconception:
treating the symptom is enough.
• C: Incorrect because ambulation is not the priority and
may worsen instability.
• D: Incorrect because fever is not “expected” and requires
immediate action.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Priority Nursing Diagnosis: Risk for infection related to
neutropenia
Related Factors/Risk Factors: Bone marrow suppression, ANC
400/mm³, mucosal barrier breakdown
Expected Outcome: The patient will receive timely cultures and
antibiotics, and temperature will begin to trend down within 24
hours.
Key Learning Objective: Identify and prioritize life-threatening
infection in the immunocompromised patient.
, 2. SATA — Safe Oral Chemotherapy Teaching
Clinical Scenario:
A patient is being discharged on an oral chemotherapy agent
and asks how to handle the medication safely at home.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash hands after contact with body fluids.
B. Crush tablets if swallowing is difficult.
C. Keep the medication in its original container away from
children.
D. Report fever, uncontrolled vomiting, or severe diarrhea
promptly.
E. Double the next dose if one dose is missed.
Correct Answers:
A, C, D
Detailed Rationale:
Oral chemotherapy requires careful handling because drug
metabolites can be present in body fluids and because dosing
errors can cause toxicity. Safety teaching includes proper
storage, infection reporting, and follow-up for adverse effects.
Incorrect Option Analysis:
