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
Clinical scenario: A patient receiving cytotoxic chemotherapy
for colorectal cancer arrives for treatment with a temperature
of 38.4°C (101.1°F), chills, and an absolute neutrophil count
(ANC) of 420/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 4 hours
B. Place the patient on protective precautions and notify the
oncology provider immediately
C. Administer an intramuscular influenza vaccine
D. Offer fresh fruit and a salad tray
Correct answer: B
Detailed rationale: Fever with severe neutropenia is a medical
emergency because the patient cannot mount an adequate
immune response. Protective precautions reduce exposure
while the provider is notified so cultures and broad-spectrum
antibiotics can be started promptly.
Incorrect option analysis:
• A: Delays care; fever in neutropenia should not be
observed passively.
, • C: Vaccination is not the priority and live vaccines are
generally avoided in immunocompromised patients.
• D: Raw foods increase infection risk in neutropenia.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty level: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Risk for Infection related to
myelosuppression
Expected outcome: The patient receives timely evaluation and
treatment for suspected febrile neutropenia.
Key learning objective: Prioritize urgent intervention for
neutropenic fever.
2) SATA
Clinical scenario: A patient is being discharged after the second
cycle of chemotherapy.
Question stem: Which teaching points should the nurse
include? (Select all that apply.)
Answer options:
A. Use a soft-bristled toothbrush
B. Report a temperature of 38°C (100.4°F) or higher
, C. Use rectal suppositories for constipation if needed
D. Avoid crowds and people who are sick
E. Take aspirin for headaches without checking first
Correct answers: A, B, D
Detailed rationale: Chemotherapy commonly causes
myelosuppression, so infection prevention and early reporting
of fever are essential. Gentle oral care reduces mucosal injury
and infection risk. Avoiding sick contacts lowers exposure.
Incorrect option analysis:
• C: Rectal medications and rectal temperatures are avoided
because they can injure mucosa and introduce infection.
• E: Aspirin can increase bleeding risk and should not be
taken without provider guidance.
Nursing process linkage: Planning / Implementation
NCJMM competencies: Recognize Cues, Generate Solutions,
Take Action
Difficulty level: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Risk for Infection related to
chemotherapy-induced immunosuppression
Expected outcome: The patient verbalizes infection precautions
and when to seek care.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
Clinical scenario: A patient receiving cytotoxic chemotherapy
for colorectal cancer arrives for treatment with a temperature
of 38.4°C (101.1°F), chills, and an absolute neutrophil count
(ANC) of 420/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 4 hours
B. Place the patient on protective precautions and notify the
oncology provider immediately
C. Administer an intramuscular influenza vaccine
D. Offer fresh fruit and a salad tray
Correct answer: B
Detailed rationale: Fever with severe neutropenia is a medical
emergency because the patient cannot mount an adequate
immune response. Protective precautions reduce exposure
while the provider is notified so cultures and broad-spectrum
antibiotics can be started promptly.
Incorrect option analysis:
• A: Delays care; fever in neutropenia should not be
observed passively.
, • C: Vaccination is not the priority and live vaccines are
generally avoided in immunocompromised patients.
• D: Raw foods increase infection risk in neutropenia.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty level: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Risk for Infection related to
myelosuppression
Expected outcome: The patient receives timely evaluation and
treatment for suspected febrile neutropenia.
Key learning objective: Prioritize urgent intervention for
neutropenic fever.
2) SATA
Clinical scenario: A patient is being discharged after the second
cycle of chemotherapy.
Question stem: Which teaching points should the nurse
include? (Select all that apply.)
Answer options:
A. Use a soft-bristled toothbrush
B. Report a temperature of 38°C (100.4°F) or higher
, C. Use rectal suppositories for constipation if needed
D. Avoid crowds and people who are sick
E. Take aspirin for headaches without checking first
Correct answers: A, B, D
Detailed rationale: Chemotherapy commonly causes
myelosuppression, so infection prevention and early reporting
of fever are essential. Gentle oral care reduces mucosal injury
and infection risk. Avoiding sick contacts lowers exposure.
Incorrect option analysis:
• C: Rectal medications and rectal temperatures are avoided
because they can injure mucosa and introduce infection.
• E: Aspirin can increase bleeding risk and should not be
taken without provider guidance.
Nursing process linkage: Planning / Implementation
NCJMM competencies: Recognize Cues, Generate Solutions,
Take Action
Difficulty level: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Risk for Infection related to
chemotherapy-induced immunosuppression
Expected outcome: The patient verbalizes infection precautions
and when to seek care.
