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 59-year-old client receiving chemotherapy
for colon cancer calls the clinic and reports a temperature of
100.9°F (38.3°C), chills, and fatigue. The most recent ANC was
500/mm³.
Stem: Which nursing action should the nurse take first?
Answer options:
A. Advise the client to drink extra fluids and recheck the
temperature in 4 hours.
B. Initiate neutropenic precautions and notify the oncology
provider immediately.
C. Encourage the client to come to clinic tomorrow if the fever
continues.
D. Suggest acetaminophen and rest at home.
Correct answer: B
Rationale: Fever with neutropenia is a medical emergency
because the client may have a rapidly progressing infection
without obvious local signs. The nurse should act immediately
to reduce exposure and expedite provider notification, cultures,
and antibiotics as ordered.
Incorrect option analysis:
A. Incorrect. Hydration is supportive but does not address the
urgent infection risk. This reflects a common misconception
,that low-grade fever can be monitored at home in
immunocompromised clients.
C. Incorrect. Delaying care increases the risk of sepsis.
D. Incorrect. Antipyretics may mask worsening infection and are
not the priority action.
Nursing process link: Implementation
NCJMM competencies: Recognize cues, Analyze cues, Prioritize
hypotheses, Take action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration: Risk for infection related to
chemotherapy-induced neutropenia
Expected outcome: The client will be evaluated and treated
promptly, with cultures and antimicrobials initiated per protocol
and no progression to sepsis.
Key learning objective: Prioritize immediate safety actions for
infection risk in oncology clients.
2) SATA — Radiation Therapy Skin Care
Clinical scenario: A 68-year-old client receiving external beam
radiation to the chest asks for home care instructions.
Stem: Which instructions should the nurse include? Select all
that apply.
, Answer options:
A. Wash the area gently with lukewarm water and mild soap.
B. Apply a heating pad if the skin feels sore.
C. Avoid direct sun exposure to the treated area.
D. Use perfume-based lotion on the skin before treatment.
E. Wear loose, soft cotton clothing.
F. Scrub the marking lines off after every shower.
Correct answers: A, C, E
Rationale: Gentle cleansing, sun protection, and friction
reduction help prevent radiation dermatitis and preserve skin
integrity during treatment.
Incorrect option analysis:
B. Incorrect. Heat can worsen skin irritation and tissue injury.
D. Incorrect. Perfumed products may irritate sensitive irradiated
skin.
F. Incorrect. Marking lines should be preserved unless the
radiation team instructs otherwise; scrubbing can damage skin
and remove necessary alignment markings.
Nursing process link: Planning / Implementation
NCJMM competencies: Recognize cues, Generate solutions,
Take action
Difficulty: Easy
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
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 59-year-old client receiving chemotherapy
for colon cancer calls the clinic and reports a temperature of
100.9°F (38.3°C), chills, and fatigue. The most recent ANC was
500/mm³.
Stem: Which nursing action should the nurse take first?
Answer options:
A. Advise the client to drink extra fluids and recheck the
temperature in 4 hours.
B. Initiate neutropenic precautions and notify the oncology
provider immediately.
C. Encourage the client to come to clinic tomorrow if the fever
continues.
D. Suggest acetaminophen and rest at home.
Correct answer: B
Rationale: Fever with neutropenia is a medical emergency
because the client may have a rapidly progressing infection
without obvious local signs. The nurse should act immediately
to reduce exposure and expedite provider notification, cultures,
and antibiotics as ordered.
Incorrect option analysis:
A. Incorrect. Hydration is supportive but does not address the
urgent infection risk. This reflects a common misconception
,that low-grade fever can be monitored at home in
immunocompromised clients.
C. Incorrect. Delaying care increases the risk of sepsis.
D. Incorrect. Antipyretics may mask worsening infection and are
not the priority action.
Nursing process link: Implementation
NCJMM competencies: Recognize cues, Analyze cues, Prioritize
hypotheses, Take action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration: Risk for infection related to
chemotherapy-induced neutropenia
Expected outcome: The client will be evaluated and treated
promptly, with cultures and antimicrobials initiated per protocol
and no progression to sepsis.
Key learning objective: Prioritize immediate safety actions for
infection risk in oncology clients.
2) SATA — Radiation Therapy Skin Care
Clinical scenario: A 68-year-old client receiving external beam
radiation to the chest asks for home care instructions.
Stem: Which instructions should the nurse include? Select all
that apply.
, Answer options:
A. Wash the area gently with lukewarm water and mild soap.
B. Apply a heating pad if the skin feels sore.
C. Avoid direct sun exposure to the treated area.
D. Use perfume-based lotion on the skin before treatment.
E. Wear loose, soft cotton clothing.
F. Scrub the marking lines off after every shower.
Correct answers: A, C, E
Rationale: Gentle cleansing, sun protection, and friction
reduction help prevent radiation dermatitis and preserve skin
integrity during treatment.
Incorrect option analysis:
B. Incorrect. Heat can worsen skin irritation and tissue injury.
D. Incorrect. Perfumed products may irritate sensitive irradiated
skin.
F. Incorrect. Marking lines should be preserved unless the
radiation team instructs otherwise; scrubbing can damage skin
and remove necessary alignment markings.
Nursing process link: Planning / Implementation
NCJMM competencies: Recognize cues, Generate solutions,
Take action
Difficulty: Easy
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
