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 with breast cancer received the
second cycle of chemotherapy 7 days ago. Today the patient
reports fatigue and chills. The temperature is 38.6°C (101.5°F),
and the absolute neutrophil count is 500/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 4 hours
B. Initiate neutropenic precautions and notify the provider
immediately
C. Give acetaminophen and reassess after pain relief
D. Teach the patient to increase fresh fruits and vegetables
Correct answer: B
Detailed rationale:
This patient has febrile neutropenia, a medical emergency in
oncology because infection can progress rapidly when
neutrophils are critically low. The nurse should initiate
protective measures and notify the provider promptly so
cultures and empiric antibiotics can be started without delay.
Incorrect option analysis:
• A: Delays urgent care. Fluids alone do not address possible
sepsis.
, • C: Acetaminophen may reduce fever but can mask
deterioration.
• D: Fresh produce can increase infection risk when counts
are low.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
• Priority nursing diagnosis: Risk for infection
• Risk factors: Chemotherapy-induced neutropenia, invasive
cancer treatment, fever
Expected outcome: The patient will receive timely
evaluation and treatment for suspected infection.
Key learning objective: Recognize and respond to febrile
neutropenia as an oncology emergency.
2) SATA — Cancer Care
Clinical scenario: A patient is receiving chemotherapy,
immunotherapy, and external beam radiation therapy for lung
cancer.
, Question stem: Which teaching points should the nurse
include? Select all that apply.
Answer options:
A. Use a soft-bristled toothbrush and electric razor
B. Report fever, sore throat, or new cough promptly
C. Apply lotion or deodorant immediately before radiation
treatment
D. Avoid crowds and people with active infections when counts
are low
E. Report diarrhea, rash, or shortness of breath during
immunotherapy
F. Scrub the irradiated skin with an abrasive washcloth after
treatment
Correct answers: A, B, D, E
Detailed rationale:
• A: Reduces bleeding risk when platelet counts may be low.
• B: Fever or respiratory symptoms may signal infection or
neutropenic fever.
• D: Helps reduce exposure when immune defenses are
suppressed.
• E: These may reflect immune-related adverse effects that
can become severe quickly.
Incorrect option analysis:
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 with breast cancer received the
second cycle of chemotherapy 7 days ago. Today the patient
reports fatigue and chills. The temperature is 38.6°C (101.5°F),
and the absolute neutrophil count is 500/mm³.
Question stem: What is the nurse’s priority action?
Answer options:
A. Encourage oral fluids and recheck the temperature in 4 hours
B. Initiate neutropenic precautions and notify the provider
immediately
C. Give acetaminophen and reassess after pain relief
D. Teach the patient to increase fresh fruits and vegetables
Correct answer: B
Detailed rationale:
This patient has febrile neutropenia, a medical emergency in
oncology because infection can progress rapidly when
neutrophils are critically low. The nurse should initiate
protective measures and notify the provider promptly so
cultures and empiric antibiotics can be started without delay.
Incorrect option analysis:
• A: Delays urgent care. Fluids alone do not address possible
sepsis.
, • C: Acetaminophen may reduce fever but can mask
deterioration.
• D: Fresh produce can increase infection risk when counts
are low.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
• Priority nursing diagnosis: Risk for infection
• Risk factors: Chemotherapy-induced neutropenia, invasive
cancer treatment, fever
Expected outcome: The patient will receive timely
evaluation and treatment for suspected infection.
Key learning objective: Recognize and respond to febrile
neutropenia as an oncology emergency.
2) SATA — Cancer Care
Clinical scenario: A patient is receiving chemotherapy,
immunotherapy, and external beam radiation therapy for lung
cancer.
, Question stem: Which teaching points should the nurse
include? Select all that apply.
Answer options:
A. Use a soft-bristled toothbrush and electric razor
B. Report fever, sore throat, or new cough promptly
C. Apply lotion or deodorant immediately before radiation
treatment
D. Avoid crowds and people with active infections when counts
are low
E. Report diarrhea, rash, or shortness of breath during
immunotherapy
F. Scrub the irradiated skin with an abrasive washcloth after
treatment
Correct answers: A, B, D, E
Detailed rationale:
• A: Reduces bleeding risk when platelet counts may be low.
• B: Fever or respiratory symptoms may signal infection or
neutropenic fever.
• D: Helps reduce exposure when immune defenses are
suppressed.
• E: These may reflect immune-related adverse effects that
can become severe quickly.
Incorrect option analysis:
