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 56-year-old patient receiving cytotoxic chemotherapy calls
the nurse reporting a temperature of 38.4°C (101.1°F), sore
throat, and mouth ulcers. The latest absolute neutrophil count
is 400/mm³.
Question Stem:
Which nursing action is the priority?
Answer Options:
A. Administer acetaminophen and reassess the temperature in
1 hour
B. Place the patient in a private room and notify the provider
immediately
C. Obtain a rectal temperature to confirm the fever
D. Encourage fresh fruits and flowers to improve appetite
Correct Answer:
B
Rationale:
This patient is at high risk for severe infection because of
profound neutropenia and fever. Protective isolation and
immediate provider notification are appropriate first actions.
Acetaminophen may mask the fever and delay treatment.
Rectal temperatures are contraindicated because they can
,introduce bacteria and cause mucosal injury. Fresh fruits and
flowers increase infection risk.
Incorrect Option Analysis:
• A: Incorrect; it treats the symptom rather than the
infection risk. Also may obscure clinical worsening.
• C: Incorrect; rectal procedures are unsafe in neutropenia.
• D: Incorrect; both can carry microorganisms.
Nursing Process Linkage: Assessment / Implementation
NCJMM Competencies: Recognize Cues; Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Safety and Infection Control
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Neutropenia, chemotherapy, mucosal
breakdown
Expected Outcome:
The patient remains free from infection complications and
receives prompt evaluation for febrile neutropenia.
Key Learning Objective:
Recognize neutropenic fever as an urgent care priority and
apply infection-prevention actions.
, 2) SATA — Cancer Care
Clinical Scenario:
A patient receiving chemotherapy reports painful oral ulcers
and reduced oral intake.
Question Stem:
Which instructions should the nurse include in the teaching
plan? Select all that apply.
Answer Options:
A. Use a soft-bristled toothbrush
B. Rinse the mouth with saline or sodium bicarbonate solution
frequently
C. Use alcohol-based mouthwash after meals
D. Report fever or chills promptly
E. Choose acidic or spicy foods to stimulate appetite
Correct Answers:
A, B, D
Rationale:
Soft oral care reduces mucosal trauma, frequent bland rinses
help keep the mouth clean, and fever/chills may indicate
infection. Alcohol-based mouthwash and spicy/acidic foods
irritate oral tissue.
Incorrect Option Analysis:
• C: Incorrect; alcohol dries and irritates mucosa.
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 56-year-old patient receiving cytotoxic chemotherapy calls
the nurse reporting a temperature of 38.4°C (101.1°F), sore
throat, and mouth ulcers. The latest absolute neutrophil count
is 400/mm³.
Question Stem:
Which nursing action is the priority?
Answer Options:
A. Administer acetaminophen and reassess the temperature in
1 hour
B. Place the patient in a private room and notify the provider
immediately
C. Obtain a rectal temperature to confirm the fever
D. Encourage fresh fruits and flowers to improve appetite
Correct Answer:
B
Rationale:
This patient is at high risk for severe infection because of
profound neutropenia and fever. Protective isolation and
immediate provider notification are appropriate first actions.
Acetaminophen may mask the fever and delay treatment.
Rectal temperatures are contraindicated because they can
,introduce bacteria and cause mucosal injury. Fresh fruits and
flowers increase infection risk.
Incorrect Option Analysis:
• A: Incorrect; it treats the symptom rather than the
infection risk. Also may obscure clinical worsening.
• C: Incorrect; rectal procedures are unsafe in neutropenia.
• D: Incorrect; both can carry microorganisms.
Nursing Process Linkage: Assessment / Implementation
NCJMM Competencies: Recognize Cues; Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Safety and Infection Control
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Neutropenia, chemotherapy, mucosal
breakdown
Expected Outcome:
The patient remains free from infection complications and
receives prompt evaluation for febrile neutropenia.
Key Learning Objective:
Recognize neutropenic fever as an urgent care priority and
apply infection-prevention actions.
, 2) SATA — Cancer Care
Clinical Scenario:
A patient receiving chemotherapy reports painful oral ulcers
and reduced oral intake.
Question Stem:
Which instructions should the nurse include in the teaching
plan? Select all that apply.
Answer Options:
A. Use a soft-bristled toothbrush
B. Rinse the mouth with saline or sodium bicarbonate solution
frequently
C. Use alcohol-based mouthwash after meals
D. Report fever or chills promptly
E. Choose acidic or spicy foods to stimulate appetite
Correct Answers:
A, B, D
Rationale:
Soft oral care reduces mucosal trauma, frequent bland rinses
help keep the mouth clean, and fever/chills may indicate
infection. Alcohol-based mouthwash and spicy/acidic foods
irritate oral tissue.
Incorrect Option Analysis:
• C: Incorrect; alcohol dries and irritates mucosa.
