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 client receiving chemotherapy for lymphoma calls the clinic
reporting a temperature of 38.6°C (101.5°F), chills, and sore
throat.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Advise the client to take acetaminophen and rest
B. Instruct the client to increase oral fluids and call back
tomorrow
C. Tell the client to come to the emergency department
immediately
D. Reassure the client that fever is expected after chemotherapy
Correct Answer
C. Tell the client to come to the emergency department
immediately
Detailed Rationale
A fever in a client receiving chemotherapy may indicate
neutropenic infection, which is a medical emergency. Rapid
,evaluation and treatment are needed because infection can
progress quickly with few early signs.
Incorrect Option Analysis
• A is incorrect: antipyretics can mask worsening infection.
• B is incorrect: delaying care increases risk of sepsis.
• D is incorrect: fever is not expected and must be treated as
urgent.
Nursing Process Linkage
Implementation
NCJMM Competencies
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty Level
Moderate
Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Nursing Diagnosis Integration
, Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppression from chemotherapy, fever,
mucosal breakdown
Expected Outcome
The client will receive urgent evaluation and antibiotic
treatment within the recommended time frame.
Key Learning Objective
Recognize oncologic emergency signs and prioritize immediate
escalation of care.
2) SATA
Clinical Scenario
A client is undergoing external beam radiation therapy to the
chest for lung cancer.
Question Stem
Which nursing instructions should the nurse include to promote
skin integrity during radiation therapy? Select all that apply.
Answer Options
A. Wash the area gently with lukewarm water
B. Apply perfumed lotion twice daily
C. Avoid tight clothing over the treatment site
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 client receiving chemotherapy for lymphoma calls the clinic
reporting a temperature of 38.6°C (101.5°F), chills, and sore
throat.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Advise the client to take acetaminophen and rest
B. Instruct the client to increase oral fluids and call back
tomorrow
C. Tell the client to come to the emergency department
immediately
D. Reassure the client that fever is expected after chemotherapy
Correct Answer
C. Tell the client to come to the emergency department
immediately
Detailed Rationale
A fever in a client receiving chemotherapy may indicate
neutropenic infection, which is a medical emergency. Rapid
,evaluation and treatment are needed because infection can
progress quickly with few early signs.
Incorrect Option Analysis
• A is incorrect: antipyretics can mask worsening infection.
• B is incorrect: delaying care increases risk of sepsis.
• D is incorrect: fever is not expected and must be treated as
urgent.
Nursing Process Linkage
Implementation
NCJMM Competencies
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty Level
Moderate
Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Nursing Diagnosis Integration
, Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Myelosuppression from chemotherapy, fever,
mucosal breakdown
Expected Outcome
The client will receive urgent evaluation and antibiotic
treatment within the recommended time frame.
Key Learning Objective
Recognize oncologic emergency signs and prioritize immediate
escalation of care.
2) SATA
Clinical Scenario
A client is undergoing external beam radiation therapy to the
chest for lung cancer.
Question Stem
Which nursing instructions should the nurse include to promote
skin integrity during radiation therapy? Select all that apply.
Answer Options
A. Wash the area gently with lukewarm water
B. Apply perfumed lotion twice daily
C. Avoid tight clothing over the treatment site
