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 — General Cancer Care: Infection Risk After
Chemotherapy
Clinical Scenario:
A 62-year-old client with non-Hodgkin lymphoma received
chemotherapy 7 days ago. The client reports chills and sore
throat. Vital signs: T 38.3°C (100.9°F), HR 108/min, BP 102/64
mm Hg. CBC shows ANC 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and reassess in 4 hours.
B. Initiate protective precautions and notify the provider
immediately.
C. Encourage the client to increase fresh fruit intake.
D. Delay assessment to avoid tiring the client.
Correct Answer:
B
Detailed Rationale:
Fever with severe neutropenia is a medical emergency because
the client is at high risk for rapid sepsis. The nurse should
implement infection-protective measures and notify the
provider promptly for cultures and likely empiric antibiotics.
Incorrect Option Analysis:
, • A: Masks the fever and delays definitive treatment.
Common misconception: treating the symptom instead of
the emergency.
• C: Fresh fruit may increase pathogen exposure and does
not address acute risk.
• D: Delaying assessment is unsafe; this client needs
immediate action.
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 Nursing Diagnosis: Risk for infection
• Risk Factors: Chemotherapy-induced neutropenia, fever,
mucosal irritation
Expected Outcome:
Client remains hemodynamically stable and receives
infection workup within 1 hour.
Key Learning Objective:
Prioritize life-threatening complications of neutropenia.
, 2) SATA — Chemotherapy Teaching and Safety
Clinical Scenario:
A client is preparing to go home after the first cycle of
chemotherapy.
Question Stem:
Which client statements indicate correct understanding of
home care? Select all that apply.
Answer Options:
A. “I will use a soft toothbrush.”
B. “I will check my temperature every day.”
C. “I will eat raw salads to improve vitamins.”
D. “I will report any unusual bruising or bleeding.”
E. “I will stop taking my antiemetic if I feel okay.”
F. “I will call the clinic if I have a temperature of 38°C (100.4°F)
or higher.”
Correct Answers:
A, B, D, F
Detailed Rationale:
Soft oral hygiene reduces mucosal trauma. Daily temperature
monitoring is essential because fever may be the only early sign
of infection. Bruising or bleeding may indicate
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — General Cancer Care: Infection Risk After
Chemotherapy
Clinical Scenario:
A 62-year-old client with non-Hodgkin lymphoma received
chemotherapy 7 days ago. The client reports chills and sore
throat. Vital signs: T 38.3°C (100.9°F), HR 108/min, BP 102/64
mm Hg. CBC shows ANC 400/mm³.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Give acetaminophen and reassess in 4 hours.
B. Initiate protective precautions and notify the provider
immediately.
C. Encourage the client to increase fresh fruit intake.
D. Delay assessment to avoid tiring the client.
Correct Answer:
B
Detailed Rationale:
Fever with severe neutropenia is a medical emergency because
the client is at high risk for rapid sepsis. The nurse should
implement infection-protective measures and notify the
provider promptly for cultures and likely empiric antibiotics.
Incorrect Option Analysis:
, • A: Masks the fever and delays definitive treatment.
Common misconception: treating the symptom instead of
the emergency.
• C: Fresh fruit may increase pathogen exposure and does
not address acute risk.
• D: Delaying assessment is unsafe; this client needs
immediate action.
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 Nursing Diagnosis: Risk for infection
• Risk Factors: Chemotherapy-induced neutropenia, fever,
mucosal irritation
Expected Outcome:
Client remains hemodynamically stable and receives
infection workup within 1 hour.
Key Learning Objective:
Prioritize life-threatening complications of neutropenia.
, 2) SATA — Chemotherapy Teaching and Safety
Clinical Scenario:
A client is preparing to go home after the first cycle of
chemotherapy.
Question Stem:
Which client statements indicate correct understanding of
home care? Select all that apply.
Answer Options:
A. “I will use a soft toothbrush.”
B. “I will check my temperature every day.”
C. “I will eat raw salads to improve vitamins.”
D. “I will report any unusual bruising or bleeding.”
E. “I will stop taking my antiemetic if I feel okay.”
F. “I will call the clinic if I have a temperature of 38°C (100.4°F)
or higher.”
Correct Answers:
A, B, D, F
Detailed Rationale:
Soft oral hygiene reduces mucosal trauma. Daily temperature
monitoring is essential because fever may be the only early sign
of infection. Bruising or bleeding may indicate
