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 client is receiving the third cycle of myelosuppressive
chemotherapy. The nurse notes a temperature of 38.4°C
(101.1°F), chills, and an absolute neutrophil count (ANC) of
650/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 4 hours
B. Initiate neutropenic precautions and notify the provider
immediately
C. Administer acetaminophen and document the finding
D. Place the client in a semi-Fowler position and reassess
respiratory rate
Correct answer: B
Detailed rationale:
This client has probable neutropenic fever, a medical
emergency in oncology care. Infection can progress rapidly
when neutrophils are low. Priority care is immediate protective
action, rapid provider notification, and escalation for cultures
and empiric antibiotics per protocol.
,Incorrect option analysis:
A is incorrect: delaying action is unsafe. Misconception:
assuming fever can be observed first.
C is incorrect: antipyretics may mask fever and do not address
the cause.
D is incorrect: respiratory support is not the priority unless
there are airway or breathing problems.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty: Difficult
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Risk for infection related to
chemotherapy-induced neutropenia; defining characteristic:
fever with low ANC
Expected outcome: The client remains hemodynamically stable
and receives antibiotic therapy without delay.
Key learning objective: Prioritize immediate protective
interventions for neutropenic fever.
2) SATA — Cancer Care, Radiation Therapy
, Clinical scenario:
A client is receiving external beam radiation to the neck and
asks about skin care and symptom management.
Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Wash the area with lukewarm water and mild soap
B. Pat the skin dry after cleansing
C. Apply adhesive tape directly over the treated skin
D. Avoid sun exposure to the irradiated area
E. Use heating pads to reduce discomfort
F. Wear soft, loose clothing over the site
Correct answers: A, B, D, F
Detailed rationale:
Radiation commonly causes skin sensitivity and irritation.
Gentle cleansing, patting dry, sun protection, and loose clothing
reduce friction and tissue injury.
Incorrect option analysis:
C is incorrect: adhesive tape can tear fragile skin.
Misconception: treating radiation skin like normal skin.
E is incorrect: heat can worsen tissue irritation and increase
damage. Patient safety concern: burns and dermatitis.
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 client is receiving the third cycle of myelosuppressive
chemotherapy. The nurse notes a temperature of 38.4°C
(101.1°F), chills, and an absolute neutrophil count (ANC) of
650/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 4 hours
B. Initiate neutropenic precautions and notify the provider
immediately
C. Administer acetaminophen and document the finding
D. Place the client in a semi-Fowler position and reassess
respiratory rate
Correct answer: B
Detailed rationale:
This client has probable neutropenic fever, a medical
emergency in oncology care. Infection can progress rapidly
when neutrophils are low. Priority care is immediate protective
action, rapid provider notification, and escalation for cultures
and empiric antibiotics per protocol.
,Incorrect option analysis:
A is incorrect: delaying action is unsafe. Misconception:
assuming fever can be observed first.
C is incorrect: antipyretics may mask fever and do not address
the cause.
D is incorrect: respiratory support is not the priority unless
there are airway or breathing problems.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty: Difficult
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control; Physiological
Adaptation
Nursing diagnosis integration: Risk for infection related to
chemotherapy-induced neutropenia; defining characteristic:
fever with low ANC
Expected outcome: The client remains hemodynamically stable
and receives antibiotic therapy without delay.
Key learning objective: Prioritize immediate protective
interventions for neutropenic fever.
2) SATA — Cancer Care, Radiation Therapy
, Clinical scenario:
A client is receiving external beam radiation to the neck and
asks about skin care and symptom management.
Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Wash the area with lukewarm water and mild soap
B. Pat the skin dry after cleansing
C. Apply adhesive tape directly over the treated skin
D. Avoid sun exposure to the irradiated area
E. Use heating pads to reduce discomfort
F. Wear soft, loose clothing over the site
Correct answers: A, B, D, F
Detailed rationale:
Radiation commonly causes skin sensitivity and irritation.
Gentle cleansing, patting dry, sun protection, and loose clothing
reduce friction and tissue injury.
Incorrect option analysis:
C is incorrect: adhesive tape can tear fragile skin.
Misconception: treating radiation skin like normal skin.
E is incorrect: heat can worsen tissue irritation and increase
damage. Patient safety concern: burns and dermatitis.
