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
Scenario:
A 54-year-old client is 10 days post-chemotherapy for
lymphoma. The client reports chills, sore throat, and weakness.
Vital signs are T 38.6°C (101.5°F), HR 112/min, BP 96/58 mm Hg.
The ANC is 400/mm³.
Stem:
What is the nurse’s priority action?
Options:
A. Give acetaminophen and reassess temperature in 1 hour
B. Notify the provider immediately and prepare to obtain blood
cultures and start antibiotics
C. Encourage oral fluids and rest
D. Document the findings and recheck vital signs at the end of
the shift
Correct Answer: B
Rationale:
This is febrile neutropenia, a medical emergency in an
immunocompromised client. The nurse should act quickly to
reduce the risk of sepsis by notifying the provider, obtaining
cultures as ordered, and preparing for prompt broad-spectrum
antibiotics.
,Incorrect Option Analysis:
A. Antipyretics may mask fever and delay treatment.
C. Fluids are supportive but do not address the urgent infection
risk.
D. Delays care and increases the risk of rapid deterioration.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Analyze Cues; Take
Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority diagnosis: Risk for infection
• Risk factors: Neutropenia, recent chemotherapy, fever
Expected Outcome: The client receives prompt infection
workup and antibiotics, and hemodynamic status remains
stable.
Key Learning Objective: Prioritize emergency intervention
for neutropenic fever.
2) SATA — Cancer Care: Neutropenic Precautions Teaching
, Scenario:
A client is being discharged after the first cycle of chemotherapy
and has an ANC below normal.
Stem:
Which instructions should the nurse include? Select all that
apply.
Options:
A. Perform hand hygiene before eating and after using the
bathroom
B. Eat raw sushi and unwashed salad for extra protein and
vitamins
C. Avoid crowds and people with obvious infections
D. Take your temperature daily and report fever promptly
E. Use rectal suppositories if constipation develops
F. Report a sore throat or temperature of 38°C (100.4°F) or
higher
Correct Answers: A, C, D, F
Rationale:
These actions reduce infection exposure and support early
detection of neutropenia-related infection. Daily temperature
checks and prompt reporting of fever are essential.
Incorrect Option Analysis:
B. Raw or undercooked foods increase infection risk.
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
Scenario:
A 54-year-old client is 10 days post-chemotherapy for
lymphoma. The client reports chills, sore throat, and weakness.
Vital signs are T 38.6°C (101.5°F), HR 112/min, BP 96/58 mm Hg.
The ANC is 400/mm³.
Stem:
What is the nurse’s priority action?
Options:
A. Give acetaminophen and reassess temperature in 1 hour
B. Notify the provider immediately and prepare to obtain blood
cultures and start antibiotics
C. Encourage oral fluids and rest
D. Document the findings and recheck vital signs at the end of
the shift
Correct Answer: B
Rationale:
This is febrile neutropenia, a medical emergency in an
immunocompromised client. The nurse should act quickly to
reduce the risk of sepsis by notifying the provider, obtaining
cultures as ordered, and preparing for prompt broad-spectrum
antibiotics.
,Incorrect Option Analysis:
A. Antipyretics may mask fever and delay treatment.
C. Fluids are supportive but do not address the urgent infection
risk.
D. Delays care and increases the risk of rapid deterioration.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Analyze Cues; Take
Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority diagnosis: Risk for infection
• Risk factors: Neutropenia, recent chemotherapy, fever
Expected Outcome: The client receives prompt infection
workup and antibiotics, and hemodynamic status remains
stable.
Key Learning Objective: Prioritize emergency intervention
for neutropenic fever.
2) SATA — Cancer Care: Neutropenic Precautions Teaching
, Scenario:
A client is being discharged after the first cycle of chemotherapy
and has an ANC below normal.
Stem:
Which instructions should the nurse include? Select all that
apply.
Options:
A. Perform hand hygiene before eating and after using the
bathroom
B. Eat raw sushi and unwashed salad for extra protein and
vitamins
C. Avoid crowds and people with obvious infections
D. Take your temperature daily and report fever promptly
E. Use rectal suppositories if constipation develops
F. Report a sore throat or temperature of 38°C (100.4°F) or
higher
Correct Answers: A, C, D, F
Rationale:
These actions reduce infection exposure and support early
detection of neutropenia-related infection. Daily temperature
checks and prompt reporting of fever are essential.
Incorrect Option Analysis:
B. Raw or undercooked foods increase infection risk.
