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 C
Explanation
A. Epoetin alfa is not administered intranasally.
B. Epoetin alfa is not administered orally because it would be destroyed by digestive enzymes and have poor absorption.
C. Epoetin alfa is typically administered subcutaneously, as it is a recombinant human erythropoietin that stimulates red blood cell production.
D. Epoetin alfa is not administered trans dermally.
Correct Answer is B
Explanation
A. Heart rate is important to monitor, but it is not the most immediate indicator of a life-threatening complication from midazolam. Changes in heart rate can occur, but they are usually secondary to respiratory issues.
B. Oxygen saturation is the priority because midazolam, a benzodiazepine, can cause respiratory depression and airway compromise. Monitoring oxygenation allows for rapid detection of hypoxia, which is the most immediate risk during moderate sedation.
C. Level of consciousness should be assessed, as midazolam causes sedation and can lead to oversedation. However, airway and breathing take priority over neurological assessment in this situation.
D. Temperature is not significantly affected by midazolam and is not an immediate concern during moderate sedation. It is therefore the lowest priority among the options provided.
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