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 receiving myelosuppressive
chemotherapy calls the clinic and reports a temperature of
38.4°C (101.1°F), sore throat, and chills.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage the patient to rest and recheck the temperature in
4 hours
B. Instruct the patient to take acetaminophen and increase
fluids
C. Have the patient come to the clinic immediately for
evaluation and notify the provider
D. Tell the patient to avoid crowds until the next scheduled
treatment
Correct answer:
C
Detailed rationale:
Fever in a patient receiving chemotherapy is an oncologic
emergency because it may indicate neutropenic infection. The
priority is prompt evaluation and provider notification so labs,
,cultures, and treatment can begin quickly. This reflects patient
safety and the nursing process priority of responding to a
potentially life-threatening cue.
Incorrect option analysis:
• A: Unsafe delay; fever may progress rapidly in neutropenia.
• B: Symptom masking without evaluation; acetaminophen
can lower fever but does not address infection.
• D: Helpful teaching for prevention, but not the immediate
priority.
Nursing process linkage: Assessment → Implementation
NCJMM competencies: Recognize Cues; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
• Priority diagnosis: Risk for Infection
• Risk factors: Chemotherapy-induced bone marrow
suppression, fever, sore throat
Expected outcome: The patient will be evaluated and
treated promptly to reduce risk of sepsis.
Key learning objective: Prioritize urgent responses to
infection cues during cancer treatment.
, 2) SATA
Clinical scenario:
A patient with metastatic melanoma is receiving immune
checkpoint inhibitor therapy and calls the oncology nurse line
with new symptoms.
Question stem:
Which findings should the nurse instruct the patient to report
immediately as possible immune-related adverse effects?
Select all that apply.
Answer options:
A. New watery diarrhea
B. Dry skin on the forearms
C. Shortness of breath
D. Yellowing of the eyes
E. Mild fatigue after a busy day
F. New severe headache and blurred vision
Correct answers:
A, C, D, F
Detailed rationale:
Immune therapies can trigger inflammation in normal tissues.
New diarrhea may signal colitis, shortness of breath may
indicate pneumonitis, jaundice can reflect hepatitis, and
headache/blurred vision may suggest endocrine or neurologic
immune toxicity. These symptoms require rapid evaluation.
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 receiving myelosuppressive
chemotherapy calls the clinic and reports a temperature of
38.4°C (101.1°F), sore throat, and chills.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Encourage the patient to rest and recheck the temperature in
4 hours
B. Instruct the patient to take acetaminophen and increase
fluids
C. Have the patient come to the clinic immediately for
evaluation and notify the provider
D. Tell the patient to avoid crowds until the next scheduled
treatment
Correct answer:
C
Detailed rationale:
Fever in a patient receiving chemotherapy is an oncologic
emergency because it may indicate neutropenic infection. The
priority is prompt evaluation and provider notification so labs,
,cultures, and treatment can begin quickly. This reflects patient
safety and the nursing process priority of responding to a
potentially life-threatening cue.
Incorrect option analysis:
• A: Unsafe delay; fever may progress rapidly in neutropenia.
• B: Symptom masking without evaluation; acetaminophen
can lower fever but does not address infection.
• D: Helpful teaching for prevention, but not the immediate
priority.
Nursing process linkage: Assessment → Implementation
NCJMM competencies: Recognize Cues; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
• Priority diagnosis: Risk for Infection
• Risk factors: Chemotherapy-induced bone marrow
suppression, fever, sore throat
Expected outcome: The patient will be evaluated and
treated promptly to reduce risk of sepsis.
Key learning objective: Prioritize urgent responses to
infection cues during cancer treatment.
, 2) SATA
Clinical scenario:
A patient with metastatic melanoma is receiving immune
checkpoint inhibitor therapy and calls the oncology nurse line
with new symptoms.
Question stem:
Which findings should the nurse instruct the patient to report
immediately as possible immune-related adverse effects?
Select all that apply.
Answer options:
A. New watery diarrhea
B. Dry skin on the forearms
C. Shortness of breath
D. Yellowing of the eyes
E. Mild fatigue after a busy day
F. New severe headache and blurred vision
Correct answers:
A, C, D, F
Detailed rationale:
Immune therapies can trigger inflammation in normal tissues.
New diarrhea may signal colitis, shortness of breath may
indicate pneumonitis, jaundice can reflect hepatitis, and
headache/blurred vision may suggest endocrine or neurologic
immune toxicity. These symptoms require rapid evaluation.
