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: Neutropenia Priority
Clinical scenario:
A client receiving chemotherapy for colon cancer reports a
temperature of 38.3°C (100.9°F), sore throat, and new chills on
day 10 after treatment.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Administer acetaminophen and reassess in 1 hour
B. Place the client in a protective isolation room immediately
C. Notify the provider and initiate neutropenic fever protocols
D. Encourage increased oral fluids and rest
Correct answer:
C
Detailed rationale:
Fever after chemotherapy is a medical emergency because it
may indicate neutropenic fever, which can rapidly progress to
sepsis. The nurse should notify the provider immediately and
initiate facility neutropenic fever protocols, including cultures
and prompt antimicrobial therapy as prescribed.
Incorrect option analysis:
• A: Incorrect. Antipyretics may mask fever and delay urgent
treatment.
, • B: Incorrect. Protective precautions are appropriate, but
the immediate priority is escalation and protocol initiation.
• D: Incorrect. Fluids and rest are supportive but not first-
line in suspected neutropenic fever.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
• Priority diagnosis: Risk for Infection
• Risk factors: Chemotherapy-induced neutropenia, mucosal
breakdown
Expected outcome: Client receives timely sepsis
prevention measures within minutes of fever recognition.
Key learning objective: Identify urgent complications of
chemotherapy and prioritize life-saving nursing actions.
2) SATA — Cancer Care: Chemotherapy, Immunotherapy,
Radiation Teaching
Clinical scenario:
A client will begin combined cancer therapy with chemotherapy
, and radiation, and the oncologist is also considering
immunotherapy.
Question stem:
Which teaching points should the nurse include? Select all that
apply.
Answer options:
A. Report fever, chills, or sore throat promptly
B. Use a soft-bristled toothbrush and electric razor if needed
C. Apply heating pads to radiation skin sites to reduce
discomfort
D. Expect immune-related symptoms such as diarrhea or cough
to be reported promptly if immunotherapy is used
E. Stop all prescribed therapy if nausea occurs
F. Protect irradiated skin from friction and sun exposure
Correct answers:
A, B, D, F
Detailed rationale:
These are key safety and self-management teaching points.
Fever may signal infection during treatment. Soft toothbrushes
and electric razors reduce bleeding risk. Immunotherapy can
cause inflammatory adverse effects, including diarrhea, cough,
rash, and endocrine changes. Radiation skin should be
protected from friction, heat, and sun exposure.
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: Neutropenia Priority
Clinical scenario:
A client receiving chemotherapy for colon cancer reports a
temperature of 38.3°C (100.9°F), sore throat, and new chills on
day 10 after treatment.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Administer acetaminophen and reassess in 1 hour
B. Place the client in a protective isolation room immediately
C. Notify the provider and initiate neutropenic fever protocols
D. Encourage increased oral fluids and rest
Correct answer:
C
Detailed rationale:
Fever after chemotherapy is a medical emergency because it
may indicate neutropenic fever, which can rapidly progress to
sepsis. The nurse should notify the provider immediately and
initiate facility neutropenic fever protocols, including cultures
and prompt antimicrobial therapy as prescribed.
Incorrect option analysis:
• A: Incorrect. Antipyretics may mask fever and delay urgent
treatment.
, • B: Incorrect. Protective precautions are appropriate, but
the immediate priority is escalation and protocol initiation.
• D: Incorrect. Fluids and rest are supportive but not first-
line in suspected neutropenic fever.
Nursing process linkage: Implementation
NCJMM competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty: Difficult
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation
Nursing diagnosis integration:
• Priority diagnosis: Risk for Infection
• Risk factors: Chemotherapy-induced neutropenia, mucosal
breakdown
Expected outcome: Client receives timely sepsis
prevention measures within minutes of fever recognition.
Key learning objective: Identify urgent complications of
chemotherapy and prioritize life-saving nursing actions.
2) SATA — Cancer Care: Chemotherapy, Immunotherapy,
Radiation Teaching
Clinical scenario:
A client will begin combined cancer therapy with chemotherapy
, and radiation, and the oncologist is also considering
immunotherapy.
Question stem:
Which teaching points should the nurse include? Select all that
apply.
Answer options:
A. Report fever, chills, or sore throat promptly
B. Use a soft-bristled toothbrush and electric razor if needed
C. Apply heating pads to radiation skin sites to reduce
discomfort
D. Expect immune-related symptoms such as diarrhea or cough
to be reported promptly if immunotherapy is used
E. Stop all prescribed therapy if nausea occurs
F. Protect irradiated skin from friction and sun exposure
Correct answers:
A, B, D, F
Detailed rationale:
These are key safety and self-management teaching points.
Fever may signal infection during treatment. Soft toothbrushes
and electric razors reduce bleeding risk. Immunotherapy can
cause inflammatory adverse effects, including diarrhea, cough,
rash, and endocrine changes. Radiation skin should be
protected from friction, heat, and sun exposure.
Incorrect option analysis:
