A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse file an incident report?
The client's absolute neutrophil count was 2,500/mm3 before the medication was administered.
The medication vial sat at room temperature for 2 hr before it was administered.
The client had chemotherapy 12 hr before the medication was administered.
The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered.
The Correct Answer is B
Choice A rationale: The client's initial neutrophil count might be within an acceptable range for filgrastim administration.
Choice B rationale: Filgrastim, a medication used to increase white blood cell count, should ideally be stored and administered as per manufacturer recommendations.
Allowing it to sit at room temperature for an extended period could affect its potency or efficacy, necessitating an incident report.
Choice C rationale: Having chemotherapy before filgrastim administration might not necessitate an incident report.
Choice D rationale: Flushing the IV line with dextrose solution is a routine practice and might not relate to the need for an incident report.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale: Polyuria (excessive urination) is not a typical manifestation of an allergic reaction to ceftriaxone.
Choice B rationale: Bradycardia is not commonly associated with an allergic reaction to ceftriaxone.
Choice C rationale: Hypotension (low blood pressure) can be a manifestation of an allergic reaction to ceftriaxone. It is crucial for the nurse to recognize this and take appropriate action.
Choice D rationale: Nausea can be a side effect of ceftriaxone but might not solely indicate an allergic reaction.
Correct Answer is B
Explanation
Choice A rationale: Massaging the site might increase bleeding or cause irritation after subcutaneous injection.
Choice B rationale: Grasping the skin between the thumb and forefinger throughout the injection helps to stabilize the tissue and minimize the risk of injecting the medication into the muscle, which could lead to increased bleeding.
Choice C rationale: Aspiration is not required for subcutaneous injections and might not influence bleeding at the injection site.
Choice D rationale: The Z-track method is typically used for intramuscular injections to prevent medication from leaking into subcutaneous tissue, but it is not appropriate for subcutaneous heparin injections.
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