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 62-year-old patient with colorectal cancer is receiving
chemotherapy and arrives for follow-up 10 days after
treatment. The patient reports a temperature of 38.4°C
(101.1°F), a sore throat, and extreme fatigue. The absolute
neutrophil count is 500/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and reassess the temperature in 1 hour.
B. Notify the provider immediately and initiate
protective/neutropenic precautions.
C. Encourage oral iron intake and rest.
D. Restrict fluids to reduce metabolic demand.
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency
because infection can progress rapidly in the setting of severe
immunosuppression. The nurse should notify the provider
immediately and begin protective precautions to reduce
,exposure to pathogens. Early recognition and urgent
intervention support timely cultures, antibiotics, and sepsis
prevention.
Incorrect Option Analysis:
• A: Acetaminophen may mask worsening infection and
delays definitive care.
• C: Iron and rest do not address the urgent infection risk.
• D: Fluid restriction can worsen perfusion and is unsafe
here.
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 Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, chemotherapy, mucosal barrier
injury
Expected Outcome:
The patient remains hemodynamically stable, infection is
escalated promptly, and empiric therapy begins without
delay.
, Key Learning Objective:
Prioritize the nursing response to febrile neutropenia.
2) SATA
Clinical Scenario:
A patient receiving a checkpoint inhibitor for metastatic
melanoma reports new watery diarrhea, a dry cough, a pruritic
rash, and a metallic taste after meals.
Question Stem:
Which findings require immediate reporting as possible
immune-related adverse effects? Select all that apply.
Answer Options:
A. Watery diarrhea 6 times in 24 hours
B. New dry cough and shortness of breath
C. Metallic taste after meals
D. Diffuse itchy rash
E. Severe headache with blurred vision
Correct Answers:
A, B, D, E
Detailed Rationale:
Checkpoint inhibitors can trigger immune-mediated toxicities
affecting the GI tract, lungs, skin, and endocrine system.
Diarrhea may indicate colitis, cough and dyspnea may indicate
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 62-year-old patient with colorectal cancer is receiving
chemotherapy and arrives for follow-up 10 days after
treatment. The patient reports a temperature of 38.4°C
(101.1°F), a sore throat, and extreme fatigue. The absolute
neutrophil count is 500/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and reassess the temperature in 1 hour.
B. Notify the provider immediately and initiate
protective/neutropenic precautions.
C. Encourage oral iron intake and rest.
D. Restrict fluids to reduce metabolic demand.
Correct Answer:
B
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency
because infection can progress rapidly in the setting of severe
immunosuppression. The nurse should notify the provider
immediately and begin protective precautions to reduce
,exposure to pathogens. Early recognition and urgent
intervention support timely cultures, antibiotics, and sepsis
prevention.
Incorrect Option Analysis:
• A: Acetaminophen may mask worsening infection and
delays definitive care.
• C: Iron and rest do not address the urgent infection risk.
• D: Fluid restriction can worsen perfusion and is unsafe
here.
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 Nursing Diagnosis: Risk for infection
• Risk Factors: Neutropenia, chemotherapy, mucosal barrier
injury
Expected Outcome:
The patient remains hemodynamically stable, infection is
escalated promptly, and empiric therapy begins without
delay.
, Key Learning Objective:
Prioritize the nursing response to febrile neutropenia.
2) SATA
Clinical Scenario:
A patient receiving a checkpoint inhibitor for metastatic
melanoma reports new watery diarrhea, a dry cough, a pruritic
rash, and a metallic taste after meals.
Question Stem:
Which findings require immediate reporting as possible
immune-related adverse effects? Select all that apply.
Answer Options:
A. Watery diarrhea 6 times in 24 hours
B. New dry cough and shortness of breath
C. Metallic taste after meals
D. Diffuse itchy rash
E. Severe headache with blurred vision
Correct Answers:
A, B, D, E
Detailed Rationale:
Checkpoint inhibitors can trigger immune-mediated toxicities
affecting the GI tract, lungs, skin, and endocrine system.
Diarrhea may indicate colitis, cough and dyspnea may indicate
