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: Neutropenic Fever Priority
Clinical scenario:
A patient receiving cycle 2 of chemotherapy for colon cancer
calls the clinic reporting a temperature of 38.4°C (101.1°F),
chills, and sore throat.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Advise the patient to take acetaminophen and rest at home.
B. Instruct the patient to increase oral fluids and recheck the
temperature in 2 hours.
C. Tell the patient to come to the clinic or emergency
department immediately.
D. Explain that fever is expected after chemotherapy and is not
concerning.
Correct answer:
C. Tell the patient to come to the clinic or emergency
department immediately.
Detailed rationale:
Fever after chemotherapy may indicate febrile neutropenia, a
medical emergency because the patient may be unable to
,mount an inflammatory response. The nurse must direct the
patient for immediate evaluation for blood cultures, CBC with
differential, and prompt antimicrobial treatment.
Incorrect option analysis:
• A: Incorrect; acetaminophen can mask fever and delay
care.
• B: Incorrect; delaying evaluation is unsafe.
• D: Incorrect; fever after chemotherapy is never something
to dismiss.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty level:
Difficult
Bloom’s level:
Apply
NCLEX client needs category:
Reduction of Risk Potential
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for infection
, Risk factors: Myelosuppression, chemotherapy, impaired host
defenses
Expected outcome:
Patient will receive urgent evaluation and treatment within the
appropriate time frame to reduce risk of sepsis.
Key learning objective:
Recognize febrile neutropenia as an oncologic emergency and
act immediately.
2) SATA — Cancer Care: Chemotherapy Self-Management
Clinical scenario:
A patient starting outpatient chemotherapy asks what
symptoms are expected and what self-care actions may help.
Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Use a soft-bristled toothbrush and rinse the mouth with
saline.
B. Report bruising or bleeding to the care team.
C. Use a straw for all beverages to prevent nausea.
D. Eat small, frequent meals if nausea occurs.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care: Neutropenic Fever Priority
Clinical scenario:
A patient receiving cycle 2 of chemotherapy for colon cancer
calls the clinic reporting a temperature of 38.4°C (101.1°F),
chills, and sore throat.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Advise the patient to take acetaminophen and rest at home.
B. Instruct the patient to increase oral fluids and recheck the
temperature in 2 hours.
C. Tell the patient to come to the clinic or emergency
department immediately.
D. Explain that fever is expected after chemotherapy and is not
concerning.
Correct answer:
C. Tell the patient to come to the clinic or emergency
department immediately.
Detailed rationale:
Fever after chemotherapy may indicate febrile neutropenia, a
medical emergency because the patient may be unable to
,mount an inflammatory response. The nurse must direct the
patient for immediate evaluation for blood cultures, CBC with
differential, and prompt antimicrobial treatment.
Incorrect option analysis:
• A: Incorrect; acetaminophen can mask fever and delay
care.
• B: Incorrect; delaying evaluation is unsafe.
• D: Incorrect; fever after chemotherapy is never something
to dismiss.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty level:
Difficult
Bloom’s level:
Apply
NCLEX client needs category:
Reduction of Risk Potential
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for infection
, Risk factors: Myelosuppression, chemotherapy, impaired host
defenses
Expected outcome:
Patient will receive urgent evaluation and treatment within the
appropriate time frame to reduce risk of sepsis.
Key learning objective:
Recognize febrile neutropenia as an oncologic emergency and
act immediately.
2) SATA — Cancer Care: Chemotherapy Self-Management
Clinical scenario:
A patient starting outpatient chemotherapy asks what
symptoms are expected and what self-care actions may help.
Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Use a soft-bristled toothbrush and rinse the mouth with
saline.
B. Report bruising or bleeding to the care team.
C. Use a straw for all beverages to prevent nausea.
D. Eat small, frequent meals if nausea occurs.
