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 patient received chemotherapy 7 days ago and
now reports chills and generalized weakness. The temperature
is 38.6°C (101.5°F), ANC is 420/mm³, and blood pressure is
96/58 mm Hg.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 1 hour
B. Place the patient on neutropenic precautions and notify the
provider immediately
C. Encourage increased oral fluids and rest
D. Teach hand hygiene before discharge
Correct answer:
B
Detailed rationale:
This patient has febrile neutropenia, a medical emergency
because infection can progress rapidly to sepsis. The priority is
to initiate protective precautions and notify the provider
immediately for urgent evaluation and likely cultures/IV
,antimicrobials. Acetaminophen may mask worsening fever.
Fluids and teaching are important, but not first.
Incorrect option analysis:
• A: Incorrect because it delays urgent intervention and may
mask fever.
• C: Incorrect because supportive care is not the priority in
suspected sepsis.
• D: Incorrect because teaching is not appropriate during an
acute unstable event.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation / Safety and
Infection Control
Nursing diagnosis integration:
Priority diagnosis: Risk for infection / Infection
Related factors: chemotherapy-induced neutropenia
Defining characteristics: fever, chills, hypotension, low ANC
Expected outcome:
Patient will receive urgent sepsis evaluation within 15 minutes
and remain hemodynamically stable.
Key learning objective:
, Recognize febrile neutropenia as an immediate priority in
cancer care.
2) SATA — Cancer Care
Clinical scenario:
A patient receiving outpatient chemotherapy asks what to do at
home to reduce infection and treatment complications.
Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Wash hands frequently
B. Report a temperature of 38°C (100.4°F) or higher
C. Use a soft toothbrush and electric razor
D. Eat raw sushi and unpasteurized cheese if appetite is poor
E. Avoid crowds and sick contacts when white blood cell counts
are low
Correct answers:
A, B, C, E
Detailed rationale:
These are standard infection-prevention and safety measures
for patients receiving chemotherapy. Hand hygiene, fever
reporting, bleeding-sparing personal care, and avoiding
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 patient received chemotherapy 7 days ago and
now reports chills and generalized weakness. The temperature
is 38.6°C (101.5°F), ANC is 420/mm³, and blood pressure is
96/58 mm Hg.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 1 hour
B. Place the patient on neutropenic precautions and notify the
provider immediately
C. Encourage increased oral fluids and rest
D. Teach hand hygiene before discharge
Correct answer:
B
Detailed rationale:
This patient has febrile neutropenia, a medical emergency
because infection can progress rapidly to sepsis. The priority is
to initiate protective precautions and notify the provider
immediately for urgent evaluation and likely cultures/IV
,antimicrobials. Acetaminophen may mask worsening fever.
Fluids and teaching are important, but not first.
Incorrect option analysis:
• A: Incorrect because it delays urgent intervention and may
mask fever.
• C: Incorrect because supportive care is not the priority in
suspected sepsis.
• D: Incorrect because teaching is not appropriate during an
acute unstable event.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation / Safety and
Infection Control
Nursing diagnosis integration:
Priority diagnosis: Risk for infection / Infection
Related factors: chemotherapy-induced neutropenia
Defining characteristics: fever, chills, hypotension, low ANC
Expected outcome:
Patient will receive urgent sepsis evaluation within 15 minutes
and remain hemodynamically stable.
Key learning objective:
, Recognize febrile neutropenia as an immediate priority in
cancer care.
2) SATA — Cancer Care
Clinical scenario:
A patient receiving outpatient chemotherapy asks what to do at
home to reduce infection and treatment complications.
Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Wash hands frequently
B. Report a temperature of 38°C (100.4°F) or higher
C. Use a soft toothbrush and electric razor
D. Eat raw sushi and unpasteurized cheese if appetite is poor
E. Avoid crowds and sick contacts when white blood cell counts
are low
Correct answers:
A, B, C, E
Detailed rationale:
These are standard infection-prevention and safety measures
for patients receiving chemotherapy. Hand hygiene, fever
reporting, bleeding-sparing personal care, and avoiding
