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
Clinical scenario:
A 62-year-old patient receiving chemotherapy for colon cancer
reports a sore throat and chills 7 days after treatment. The
temperature is 38.4°C (101.1°F), and the ANC is 450/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and reassess in 1 hour
B. Place the patient in protective precautions and notify the
provider immediately
C. Give acetaminophen and document the result
D. Obtain a sputum specimen before taking any further action
Correct answer:
B
Detailed rationale:
This patient has febrile neutropenia, a medical emergency
because infection can progress rapidly when the neutrophil
count is severely low. Protective precautions and immediate
provider notification are priorities. The nurse should also
anticipate blood cultures and broad-spectrum antibiotics.
Incorrect option analysis:
, • A: Oral fluids are helpful, but fever with severe
neutropenia is not a “wait and reassess” situation.
• C: Antipyretics may mask the fever and delay treatment.
• D: Cultures may be obtained, but stabilizing and escalating
care come first.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs:
Physiological Adaptation; Safety and Infection Control
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for Infection
Risk factors: Chemotherapy-induced neutropenia, invasive
cancer treatment
Expected outcome: Patient receives prompt evaluation and
antimicrobial therapy without delay
Key learning objective: Recognize and respond to life-
threatening infection risk in neutropenic patients
, 2) SATA — Cancer Care: Immunotherapy Adverse Effects
Clinical scenario:
A patient receiving immune checkpoint inhibitor therapy for
melanoma calls the clinic with several new symptoms.
Question stem:
Which symptoms should the nurse instruct the patient to report
immediately? Select all that apply.
Answer options:
A. New cough and shortness of breath
B. Mild fatigue after treatment
C. Severe diarrhea
D. Yellowing of the skin
E. Temporary metallic taste in the mouth
Correct answers:
A, C, D
Detailed rationale:
Immune-related adverse effects can affect the lungs, bowel,
liver, and other organs. New respiratory symptoms may indicate
pneumonitis, severe diarrhea may indicate colitis, and jaundice
may signal hepatitis. These require prompt evaluation.
Incorrect option analysis:
• B: Mild fatigue can be expected after treatment and is not
by itself an urgent red flag.
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
Clinical scenario:
A 62-year-old patient receiving chemotherapy for colon cancer
reports a sore throat and chills 7 days after treatment. The
temperature is 38.4°C (101.1°F), and the ANC is 450/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and reassess in 1 hour
B. Place the patient in protective precautions and notify the
provider immediately
C. Give acetaminophen and document the result
D. Obtain a sputum specimen before taking any further action
Correct answer:
B
Detailed rationale:
This patient has febrile neutropenia, a medical emergency
because infection can progress rapidly when the neutrophil
count is severely low. Protective precautions and immediate
provider notification are priorities. The nurse should also
anticipate blood cultures and broad-spectrum antibiotics.
Incorrect option analysis:
, • A: Oral fluids are helpful, but fever with severe
neutropenia is not a “wait and reassess” situation.
• C: Antipyretics may mask the fever and delay treatment.
• D: Cultures may be obtained, but stabilizing and escalating
care come first.
Nursing process linkage:
Implementation
NCJMM competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs:
Physiological Adaptation; Safety and Infection Control
Nursing diagnosis integration:
Priority nursing diagnosis: Risk for Infection
Risk factors: Chemotherapy-induced neutropenia, invasive
cancer treatment
Expected outcome: Patient receives prompt evaluation and
antimicrobial therapy without delay
Key learning objective: Recognize and respond to life-
threatening infection risk in neutropenic patients
, 2) SATA — Cancer Care: Immunotherapy Adverse Effects
Clinical scenario:
A patient receiving immune checkpoint inhibitor therapy for
melanoma calls the clinic with several new symptoms.
Question stem:
Which symptoms should the nurse instruct the patient to report
immediately? Select all that apply.
Answer options:
A. New cough and shortness of breath
B. Mild fatigue after treatment
C. Severe diarrhea
D. Yellowing of the skin
E. Temporary metallic taste in the mouth
Correct answers:
A, C, D
Detailed rationale:
Immune-related adverse effects can affect the lungs, bowel,
liver, and other organs. New respiratory symptoms may indicate
pneumonitis, severe diarrhea may indicate colitis, and jaundice
may signal hepatitis. These require prompt evaluation.
Incorrect option analysis:
• B: Mild fatigue can be expected after treatment and is not
by itself an urgent red flag.
