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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Citalopram is a selective serotonin reuptake inhibitor (SSRI) that increases the level of serotonin in the brain. Serotonin syndrome is a rare but serious adverse effect of SSRIs that can cause confusion, agitation, tremors, seizures, and coma. The nurse should report this finding to the provider immediately, as it can be life-threatening.
Choice B rationale: Insomnia can occur as an adverse effect of citalopram but might not be as immediately concerning as confusion.
Choice C rationale: Bruxism (teeth grinding) can be a side effect of citalopram but might not pose an immediate risk compared to confusion.
Choice D rationale: Weight loss, while a potential side effect, might not be as urgent or immediately concerning as confusion.
Correct Answer is C
Explanation
Choice A rationale: While increased blood pressure can occur in various conditions, it might not specifically indicate anaphylaxis to penicillin.
Choice B rationale: Hypertonia might not directly correlate with anaphylaxis and could be caused by other factors.
Choice C rationale: Wheezing is a critical sign of anaphylaxis, a severe allergic reaction to penicillin. Reporting wheezing to the provider is crucial for immediate intervention to prevent further complications associated with anaphylaxis.
Choice D rationale: Urinary retention is not a typical manifestation of anaphylaxis to penicillin and might not be directly linked to the allergic reaction.
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