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
Clinical Scenario:
A 56-year-old patient receiving the second cycle of
chemotherapy calls the nurse from the infusion clinic and
reports chills, sore throat, and a temperature of 38.2°C
(100.8°F). The most recent ANC is 400 cells/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Notify the oncology provider immediately and prepare to
obtain cultures per protocol
B. Encourage oral fluids and recheck the temperature in 1 hour
C. Give acetaminophen and discharge the patient with home
instructions
D. Place the patient in a shared room to reduce isolation
Correct Answer:
A
Detailed Rationale:
This is febrile neutropenia until proven otherwise. The patient
has fever, chills, and profound neutropenia, which creates a
high risk for rapid sepsis. The nurse must act quickly to support
early cultures and treatment.
,Incorrect Option Analysis:
• B: Delays care; febrile neutropenia is an emergency.
• C: Masks the fever and delays definitive treatment.
• D: Increases infection risk and is unsafe.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Safety and Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Neutropenia, chemotherapy, fever, mucosal
barrier injury
Expected Outcome:
The patient will receive sepsis-prevention interventions and
antibiotics will be initiated promptly per protocol.
, Key Learning Objective:
Prioritize emergency actions for febrile neutropenia.
2) SATA — Cancer Care
Clinical Scenario:
A patient is being discharged after the first cycle of oral
chemotherapy. The nurse is reinforcing home safety teaching to
reduce infection and bleeding risk.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Monitor temperature every day and report fever promptly
B. Use a soft toothbrush and electric razor
C. Avoid crowds and people with respiratory illness
D. Report bruising, bleeding, or black stools
E. Take live vaccines to prevent infection
F. Use aspirin freely for headaches
Correct Answers:
A, B, C, D
Detailed Rationale:
These measures reduce infection and bleeding complications
from therapy-related bone marrow suppression.
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care
Clinical Scenario:
A 56-year-old patient receiving the second cycle of
chemotherapy calls the nurse from the infusion clinic and
reports chills, sore throat, and a temperature of 38.2°C
(100.8°F). The most recent ANC is 400 cells/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Notify the oncology provider immediately and prepare to
obtain cultures per protocol
B. Encourage oral fluids and recheck the temperature in 1 hour
C. Give acetaminophen and discharge the patient with home
instructions
D. Place the patient in a shared room to reduce isolation
Correct Answer:
A
Detailed Rationale:
This is febrile neutropenia until proven otherwise. The patient
has fever, chills, and profound neutropenia, which creates a
high risk for rapid sepsis. The nurse must act quickly to support
early cultures and treatment.
,Incorrect Option Analysis:
• B: Delays care; febrile neutropenia is an emergency.
• C: Masks the fever and delays definitive treatment.
• D: Increases infection risk and is unsafe.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Safety and Infection Control
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Neutropenia, chemotherapy, fever, mucosal
barrier injury
Expected Outcome:
The patient will receive sepsis-prevention interventions and
antibiotics will be initiated promptly per protocol.
, Key Learning Objective:
Prioritize emergency actions for febrile neutropenia.
2) SATA — Cancer Care
Clinical Scenario:
A patient is being discharged after the first cycle of oral
chemotherapy. The nurse is reinforcing home safety teaching to
reduce infection and bleeding risk.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Monitor temperature every day and report fever promptly
B. Use a soft toothbrush and electric razor
C. Avoid crowds and people with respiratory illness
D. Report bruising, bleeding, or black stools
E. Take live vaccines to prevent infection
F. Use aspirin freely for headaches
Correct Answers:
A, B, C, D
Detailed Rationale:
These measures reduce infection and bleeding complications
from therapy-related bone marrow suppression.
