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: Neutropenic Fever
Clinical Scenario:
A 58-year-old client with lymphoma is 10 days post-
chemotherapy and reports chills, weakness, and a sore throat.
Vital signs are T 38.6°C (101.5°F), HR 108/min, BP 98/60 mm Hg.
The ANC is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and encourage oral fluids
B. Obtain blood cultures per protocol and notify the provider
immediately
C. Place the client on contact precautions
D. Reassure the client that fever is expected after chemotherapy
Correct Answer:
B
Detailed Rationale:
This client has febrile neutropenia, a medical emergency. The
nurse should obtain cultures promptly and notify the provider
immediately so broad-spectrum antibiotics can be started
quickly, usually after cultures are collected. Fever in
neutropenia may be the only sign of infection.
,Incorrect Option Analysis:
• A: Acetaminophen can mask fever and delay treatment;
oral fluids do not address the emergency.
• C: Neutropenic precautions are appropriate, but they do
not replace urgent infection workup and treatment.
• D: Fever is not expected or benign in this context; this is
unsafe reassurance.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection / Actual Infection
Related Factors: Neutropenia, chemotherapy-induced
immunosuppression
Defining Characteristics: Fever, chills, sore throat, hypotension
, Expected Outcome:
Blood cultures are obtained promptly, and antimicrobial
therapy begins without delay.
Key Learning Objective:
Prioritize urgent interventions for infection risk in the
immunocompromised client.
2) SATA — Cancer Care: Radiation Skin Care
Clinical Scenario:
A client receiving external beam radiation therapy for breast
cancer asks how to care for the skin in the treatment area.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with mild soap and lukewarm water
B. Apply lotion only if it is prescribed or approved by the
radiation team
C. Expose the area to sunlight to promote healing
D. Pat the area dry rather than rubbing it
E. Use a heating pad on the treated site for comfort
F. Wear loose, soft clothing over the area
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care: Neutropenic Fever
Clinical Scenario:
A 58-year-old client with lymphoma is 10 days post-
chemotherapy and reports chills, weakness, and a sore throat.
Vital signs are T 38.6°C (101.5°F), HR 108/min, BP 98/60 mm Hg.
The ANC is 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and encourage oral fluids
B. Obtain blood cultures per protocol and notify the provider
immediately
C. Place the client on contact precautions
D. Reassure the client that fever is expected after chemotherapy
Correct Answer:
B
Detailed Rationale:
This client has febrile neutropenia, a medical emergency. The
nurse should obtain cultures promptly and notify the provider
immediately so broad-spectrum antibiotics can be started
quickly, usually after cultures are collected. Fever in
neutropenia may be the only sign of infection.
,Incorrect Option Analysis:
• A: Acetaminophen can mask fever and delay treatment;
oral fluids do not address the emergency.
• C: Neutropenic precautions are appropriate, but they do
not replace urgent infection workup and treatment.
• D: Fever is not expected or benign in this context; this is
unsafe reassurance.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Risk for Infection / Actual Infection
Related Factors: Neutropenia, chemotherapy-induced
immunosuppression
Defining Characteristics: Fever, chills, sore throat, hypotension
, Expected Outcome:
Blood cultures are obtained promptly, and antimicrobial
therapy begins without delay.
Key Learning Objective:
Prioritize urgent interventions for infection risk in the
immunocompromised client.
2) SATA — Cancer Care: Radiation Skin Care
Clinical Scenario:
A client receiving external beam radiation therapy for breast
cancer asks how to care for the skin in the treatment area.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Wash the area gently with mild soap and lukewarm water
B. Apply lotion only if it is prescribed or approved by the
radiation team
C. Expose the area to sunlight to promote healing
D. Pat the area dry rather than rubbing it
E. Use a heating pad on the treated site for comfort
F. Wear loose, soft clothing over the area
