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 patient receiving the second cycle of chemotherapy reports
chills, weakness, and a temperature of 38.4°C (101.1°F). The
nurse notes an absolute neutrophil count of 500/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and recheck temperature in 1 hour
B. Initiate neutropenic precautions and notify the provider
immediately
C. Give acetaminophen and document the finding
D. Place the patient on a high-protein diet
Correct Answer:
B
Detailed Rationale:
Fever with neutropenia is a medical emergency because the
patient cannot mount a normal immune response. Safety-
focused care planning requires immediate protective
precautions and rapid escalation.
Incorrect Option Analysis:
, • A: Delays care; fever in neutropenia is not managed by
observation alone.
• C: May mask fever and delay definitive treatment.
• D: Nutrition matters, but it is not the priority.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Chemotherapy-induced neutropenia,
impaired immune response
Expected Outcome:
The patient remains free from signs of sepsis and receives
prompt treatment within the shift.
Key Learning Objective:
Prioritize immediate safety interventions for chemotherapy-
related neutropenia.
, 2) SATA — Cancer Care
Clinical Scenario:
A patient is starting external beam radiation to the chest.
Question Stem:
Which teaching points should the nurse include? Select all that
apply.
Answer Options:
A. Wash the treated skin gently with lukewarm water
B. Apply adhesive tape over the treatment area if needed
C. Wear loose, soft clothing over the area
D. Use only lotions approved by the radiation team
E. Scrub the site with a washcloth to remove marks
F. Protect the skin from sun exposure
Correct Answers:
A, C, D, F
Detailed Rationale:
Radiation can make skin fragile and sensitive. Care planning
focuses on minimizing irritation and preventing breakdown.
Incorrect Option Analysis:
• B: Adhesives can traumatize the skin.
• E: Scrubbing increases skin injury and discomfort.
Nursing Process Linkage: Implementation
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 patient receiving the second cycle of chemotherapy reports
chills, weakness, and a temperature of 38.4°C (101.1°F). The
nurse notes an absolute neutrophil count of 500/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage oral fluids and recheck temperature in 1 hour
B. Initiate neutropenic precautions and notify the provider
immediately
C. Give acetaminophen and document the finding
D. Place the patient on a high-protein diet
Correct Answer:
B
Detailed Rationale:
Fever with neutropenia is a medical emergency because the
patient cannot mount a normal immune response. Safety-
focused care planning requires immediate protective
precautions and rapid escalation.
Incorrect Option Analysis:
, • A: Delays care; fever in neutropenia is not managed by
observation alone.
• C: May mask fever and delay definitive treatment.
• D: Nutrition matters, but it is not the priority.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for Infection
• Risk Factors: Chemotherapy-induced neutropenia,
impaired immune response
Expected Outcome:
The patient remains free from signs of sepsis and receives
prompt treatment within the shift.
Key Learning Objective:
Prioritize immediate safety interventions for chemotherapy-
related neutropenia.
, 2) SATA — Cancer Care
Clinical Scenario:
A patient is starting external beam radiation to the chest.
Question Stem:
Which teaching points should the nurse include? Select all that
apply.
Answer Options:
A. Wash the treated skin gently with lukewarm water
B. Apply adhesive tape over the treatment area if needed
C. Wear loose, soft clothing over the area
D. Use only lotions approved by the radiation team
E. Scrub the site with a washcloth to remove marks
F. Protect the skin from sun exposure
Correct Answers:
A, C, D, F
Detailed Rationale:
Radiation can make skin fragile and sensitive. Care planning
focuses on minimizing irritation and preventing breakdown.
Incorrect Option Analysis:
• B: Adhesives can traumatize the skin.
• E: Scrubbing increases skin injury and discomfort.
Nursing Process Linkage: Implementation
