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 with colorectal cancer is receiving
chemotherapy. The patient reports chills, oral soreness, and
feeling weak. Vital signs show temperature 38.3°C (100.9°F).
The ANC is 500 cells/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and reassess the temperature in 1 hour.
B. Notify the oncology provider immediately and initiate
neutropenic precautions.
C. Encourage visitors to wear masks and continue routine care.
D. Delay documentation until the next medication round.
Correct Answer:
B
Detailed Rationale:
Fever with a severely low ANC indicates febrile neutropenia, a
medical emergency in oncology care. The nurse must act
immediately to reduce infection risk and escalate care.
Protective precautions and provider notification support rapid
evaluation and treatment.
,Incorrect Option Analysis:
• A: Masks the symptom and delays urgent treatment;
acetaminophen may lower the fever without addressing
the cause.
• C: Infection control is important, but routine care is unsafe
in suspected febrile neutropenia.
• D: Documentation is important, but not before immediate
action.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Analyze Cues; Take Action
Difficulty / Bloom / NCLEX Client Needs:
Moderate / Apply / Reduction of Risk Potential; Safety and
Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for infection
Related Factors: Myelosuppression secondary to chemotherapy
Risk Factors / Defining Cues: Fever, ANC 500, chills, oral
mucosal breakdown
Expected Outcome:
The patient will receive prompt evaluation and infection-control
, measures, with antibiotics initiated per protocol and
temperature monitored closely.
Key Learning Objective:
Prioritize urgent intervention for febrile neutropenia in
chemotherapy care.
2) SATA — Cancer Care
Clinical Scenario:
A patient receiving chemotherapy reports nausea, mouth
soreness, and reduced appetite. The nurse is developing a
supportive care plan.
Question Stem:
Which interventions should the nurse include? Select all that
apply.
Answer Options:
A. Use a soft-bristled toothbrush and saline or baking soda
mouth rinses.
B. Encourage small, frequent meals throughout the day.
C. Recommend alcohol-based mouthwash to reduce oral
bacteria.
D. Monitor daily weight and hydration status.
E. Encourage spicy, citrus, and hot foods to stimulate appetite.
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 with colorectal cancer is receiving
chemotherapy. The patient reports chills, oral soreness, and
feeling weak. Vital signs show temperature 38.3°C (100.9°F).
The ANC is 500 cells/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and reassess the temperature in 1 hour.
B. Notify the oncology provider immediately and initiate
neutropenic precautions.
C. Encourage visitors to wear masks and continue routine care.
D. Delay documentation until the next medication round.
Correct Answer:
B
Detailed Rationale:
Fever with a severely low ANC indicates febrile neutropenia, a
medical emergency in oncology care. The nurse must act
immediately to reduce infection risk and escalate care.
Protective precautions and provider notification support rapid
evaluation and treatment.
,Incorrect Option Analysis:
• A: Masks the symptom and delays urgent treatment;
acetaminophen may lower the fever without addressing
the cause.
• C: Infection control is important, but routine care is unsafe
in suspected febrile neutropenia.
• D: Documentation is important, but not before immediate
action.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Analyze Cues; Take Action
Difficulty / Bloom / NCLEX Client Needs:
Moderate / Apply / Reduction of Risk Potential; Safety and
Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for infection
Related Factors: Myelosuppression secondary to chemotherapy
Risk Factors / Defining Cues: Fever, ANC 500, chills, oral
mucosal breakdown
Expected Outcome:
The patient will receive prompt evaluation and infection-control
, measures, with antibiotics initiated per protocol and
temperature monitored closely.
Key Learning Objective:
Prioritize urgent intervention for febrile neutropenia in
chemotherapy care.
2) SATA — Cancer Care
Clinical Scenario:
A patient receiving chemotherapy reports nausea, mouth
soreness, and reduced appetite. The nurse is developing a
supportive care plan.
Question Stem:
Which interventions should the nurse include? Select all that
apply.
Answer Options:
A. Use a soft-bristled toothbrush and saline or baking soda
mouth rinses.
B. Encourage small, frequent meals throughout the day.
C. Recommend alcohol-based mouthwash to reduce oral
bacteria.
D. Monitor daily weight and hydration status.
E. Encourage spicy, citrus, and hot foods to stimulate appetite.
