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 68-year-old patient with colorectal cancer is receiving a
second cycle of chemotherapy. The patient reports a sore
throat, feels weak, and has a temperature of 38.4°C (101.1°F).
The absolute neutrophil count is 700/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage increased oral fluids and rest
B. Administer acetaminophen and reassess in 4 hours
C. Initiate neutropenic precautions and notify the provider
immediately
D. Delay the chemotherapy dose until the next clinic visit
Correct Answer:
C. Initiate neutropenic precautions and notify the provider
immediately
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency in
oncology. The priority is to reduce infection exposure and
escalate care quickly so cultures, broad-spectrum antibiotics,
,and further sepsis evaluation can occur. Fever with neutropenia
is treated as urgent because infection may progress rapidly.
Incorrect Option Analysis:
• A: Fluids and rest are supportive, but this does not address
the emergency.
• B: Acetaminophen may mask fever and delay recognition
of worsening infection.
• D: Delaying chemotherapy does not address the
immediate risk.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Recognize Cues; Prioritize
Hypotheses; Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection / actual
infection
• Related Factors: Myelosuppression from chemotherapy
• Defining Characteristics: Fever, sore throat, neutropenia
Expected Outcome:
The patient remains free from sepsis complications and
receives prompt antimicrobial treatment.
, Key Learning Objective:
Recognize and act on oncologic infection risk linked to
neutropenia.
2) SATA
Clinical Scenario:
A patient receiving outpatient chemotherapy asks how to
reduce complications at home.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Report a temperature of 38°C (100.4°F) or higher
immediately
B. Use a soft toothbrush and electric razor
C. Take aspirin for body aches if needed
D. Avoid raw fruits, raw vegetables, and unpasteurized foods if
advised by the oncology team
E. Keep all scheduled laboratory appointments
Correct Answers:
A, B, D, E
Detailed Rationale:
These actions reduce the risk of infection and bleeding and
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 68-year-old patient with colorectal cancer is receiving a
second cycle of chemotherapy. The patient reports a sore
throat, feels weak, and has a temperature of 38.4°C (101.1°F).
The absolute neutrophil count is 700/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage increased oral fluids and rest
B. Administer acetaminophen and reassess in 4 hours
C. Initiate neutropenic precautions and notify the provider
immediately
D. Delay the chemotherapy dose until the next clinic visit
Correct Answer:
C. Initiate neutropenic precautions and notify the provider
immediately
Detailed Rationale:
This patient has febrile neutropenia, a medical emergency in
oncology. The priority is to reduce infection exposure and
escalate care quickly so cultures, broad-spectrum antibiotics,
,and further sepsis evaluation can occur. Fever with neutropenia
is treated as urgent because infection may progress rapidly.
Incorrect Option Analysis:
• A: Fluids and rest are supportive, but this does not address
the emergency.
• B: Acetaminophen may mask fever and delay recognition
of worsening infection.
• D: Delaying chemotherapy does not address the
immediate risk.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Recognize Cues; Prioritize
Hypotheses; Take Action
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Risk for infection / actual
infection
• Related Factors: Myelosuppression from chemotherapy
• Defining Characteristics: Fever, sore throat, neutropenia
Expected Outcome:
The patient remains free from sepsis complications and
receives prompt antimicrobial treatment.
, Key Learning Objective:
Recognize and act on oncologic infection risk linked to
neutropenia.
2) SATA
Clinical Scenario:
A patient receiving outpatient chemotherapy asks how to
reduce complications at home.
Question Stem:
Which instructions should the nurse include? Select all that
apply.
Answer Options:
A. Report a temperature of 38°C (100.4°F) or higher
immediately
B. Use a soft toothbrush and electric razor
C. Take aspirin for body aches if needed
D. Avoid raw fruits, raw vegetables, and unpasteurized foods if
advised by the oncology team
E. Keep all scheduled laboratory appointments
Correct Answers:
A, B, D, E
Detailed Rationale:
These actions reduce the risk of infection and bleeding and
