A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?
The client had a decreased neutrophil count before the medication was administered.
The client had chemotherapy 12 hr before the medication was administered.
The vial was out of the refrigerator for 2 hr before the medication was administered.
The client reported feeling nauseous after the medication was administered.
The Correct Answer is C
A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:
Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. "Consumption of a high protein meal can reduce the effectiveness of the medication."
High-protein meals can interfere with levodopa absorption in the intestine, reducing its effectiveness. Clients should consume protein in moderate amounts and distribute intake throughout the day.
B. "You may notice your urine becomes lighter in color."
Levodopa can cause urine, sweat, and saliva to become darker (brown, red, or black), not lighter. This is a harmless side effect but should be discussed with the client.
C. "You may initially notice an increase in involuntary movements."
Levodopa can cause dyskinesia (involuntary movements), especially with prolonged use or at higher doses. These movements can include facial twitching, jerking, or head bobbing.
D. "The medication can cause nausea, so take with a meal."
Levodopa can cause nausea, particularly when first starting the medication. Taking it with food can help reduce gastrointestinal discomfort, but avoiding high-protein meals is important.
E. "This medication can make you light-headed if you stand up too quickly from a seated or lying position."
Levodopa can cause orthostatic hypotension, leading to dizziness or light-headedness when changing positions. Clients should be advised to rise slowly to prevent falls.
Correct Answer is B
Explanation
A. Increase in serum sodium: Desmopressin, a synthetic form of vasopressin, works to decrease urine output and increase water reabsorption in the kidneys. Therefore, a therapeutic response to desmopressin would not result in an increase in serum sodium; rather, it would aim to normalize serum sodium levels by reducing excessive urine output.
B. Decrease in urine output: The primary therapeutic goal of desmopressin in the treatment of diabetes insipidus is to decrease urine output by increasing water reabsorption in the kidneys. Therefore, a decrease in urine output would indicate a positive response to the medication.
C. Increase in heart rate: Desmopressin primarily affects kidney function by increasing water reabsorption and does not typically have a direct effect on heart rate. Therefore, an increase in heart rate would not be a manifestation of a therapeutic response to desmopressin.
D. Decrease in blood pressure: Desmopressin works to increase water reabsorption in the kidneys and does not typically cause significant changes in blood pressure. Therefore, a decrease in blood pressure would not be a manifestation of a therapeutic response to desmopressin.
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