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 62-year-old client with acute myeloid leukemia is on day 10
after chemotherapy. The client reports chills and a sore throat.
Vital signs: T 38.4°C (101.1°F), HR 108/min, BP 118/70 mm Hg.
ANC is 300/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 2 hours
B. Place the client on protective precautions and notify the
provider immediately
C. Encourage ambulation to prevent pneumonia
D. Obtain a rectal temperature to confirm the fever
Correct answer:
B
Detailed rationale:
This client has febrile neutropenia, which is an oncologic
emergency. The nurse should implement infection-protection
measures and notify the provider promptly so cultures and
empiric antibiotics can be initiated. Delay increases the risk of
sepsis.
,Incorrect option analysis:
• A: Masks the fever and delays urgent treatment. Common
misconception: treating symptoms first is enough.
• C: Ambulation is not the priority and may increase
exposure to pathogens.
• D: Rectal temperatures are avoided in neutropenic clients
because they can injure mucosa and introduce infection.
Nursing process link: Implementation
NCJMM: Recognize Cues; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Risk for Infection r/t bone
marrow suppression
Expected outcome: Client remains free from infection-related
complications and receives timely treatment.
Key learning objective: Identify the immediate nursing
response to febrile neutropenia.
2) SATA — Cancer Care
Clinical scenario:
A client receiving outpatient chemotherapy is being discharged
after treatment. The nurse is reviewing home precautions.
, Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Use a soft toothbrush and electric razor
B. Report a temperature of 38°C (100.4°F) or higher
C. Eat raw fruits and salads daily to prevent constipation
D. Avoid crowds and people who are ill
E. Stop antiemetics once nausea begins
F. Report unusual bruising or bleeding
Correct answers:
A, B, D, F
Detailed rationale:
Chemotherapy can cause neutropenia and thrombocytopenia.
Soft oral care and electric razors reduce bleeding risk. Fever is
an emergency. Avoiding exposure lowers infection risk. Bruising
or bleeding can signal low platelets.
Incorrect option analysis:
• C: Raw produce may increase infection risk during
neutropenia.
• E: Antiemetics are most effective when taken as
prescribed, often before nausea becomes severe.
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 62-year-old client with acute myeloid leukemia is on day 10
after chemotherapy. The client reports chills and a sore throat.
Vital signs: T 38.4°C (101.1°F), HR 108/min, BP 118/70 mm Hg.
ANC is 300/mm³.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Give acetaminophen and reassess in 2 hours
B. Place the client on protective precautions and notify the
provider immediately
C. Encourage ambulation to prevent pneumonia
D. Obtain a rectal temperature to confirm the fever
Correct answer:
B
Detailed rationale:
This client has febrile neutropenia, which is an oncologic
emergency. The nurse should implement infection-protection
measures and notify the provider promptly so cultures and
empiric antibiotics can be initiated. Delay increases the risk of
sepsis.
,Incorrect option analysis:
• A: Masks the fever and delays urgent treatment. Common
misconception: treating symptoms first is enough.
• C: Ambulation is not the priority and may increase
exposure to pathogens.
• D: Rectal temperatures are avoided in neutropenic clients
because they can injure mucosa and introduce infection.
Nursing process link: Implementation
NCJMM: Recognize Cues; Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Safety and Infection Control
Nursing diagnosis integration: Risk for Infection r/t bone
marrow suppression
Expected outcome: Client remains free from infection-related
complications and receives timely treatment.
Key learning objective: Identify the immediate nursing
response to febrile neutropenia.
2) SATA — Cancer Care
Clinical scenario:
A client receiving outpatient chemotherapy is being discharged
after treatment. The nurse is reviewing home precautions.
, Question stem:
Which instructions should the nurse include? Select all that
apply.
Answer options:
A. Use a soft toothbrush and electric razor
B. Report a temperature of 38°C (100.4°F) or higher
C. Eat raw fruits and salads daily to prevent constipation
D. Avoid crowds and people who are ill
E. Stop antiemetics once nausea begins
F. Report unusual bruising or bleeding
Correct answers:
A, B, D, F
Detailed rationale:
Chemotherapy can cause neutropenia and thrombocytopenia.
Soft oral care and electric razors reduce bleeding risk. Fever is
an emergency. Avoiding exposure lowers infection risk. Bruising
or bleeding can signal low platelets.
Incorrect option analysis:
• C: Raw produce may increase infection risk during
neutropenia.
• E: Antiemetics are most effective when taken as
prescribed, often before nausea becomes severe.
