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 had chemotherapy 12 hr before the medication was administered.
The medication vial sat at room temperature for 2 hr before it was administered.
The client's absolute neutrophil count was 2,500/mm³ 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 A
Choice A rationale: Administering filgrastim after chemotherapy is a standard practice to boost white blood cell count. However, filgrastim should not be given within 24 hours before or after chemotherapy, as it can affect the efficacy and increase the risk of side effects. Administering the medication 12 hours after chemotherapy falls within this contraindicated window, necessitating an incident report.
Choice B rationale: Filgrastim can be stored at room temperature for short periods, and 2 hours is generally within acceptable limits for stability.
Choice C rationale: An absolute neutrophil count of 2,500/mm³ is within the normal range, and there is no contraindication for administering filgrastim.
Choice D rationale: Flushing the client's IV line with dextrose 5% in water before and after administering filgrastim is not appropriate, as this medication is typically administered with saline solution. Using an incorrect flushing solution could affect the medication's efficacy or compatibility, necessitating an incident report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When administering heparin subcutaneously, the nurse should grasp the skin between the thumb and forefinger throughout the injection to minimize bleeding following the injection.
Choice A is wrong because Use the Z-track method to administer the medication, is not the correct answer because the Z-track method is a technique used for intramuscular injections, not subcutaneous injections.
Choice C is wrong because Aspirate the syringe prior to injecting the heparin, is not the correct answer because aspiration is not necessary when administering heparin subcutaneously.
Choice D is wrong because Gently massage the site following the injection, is not the correct answer because massaging the injection site can increase the risk of bruising and bleeding.
Correct Answer is A
Explanation
The correct answer is choice A. Increased pulse rate.
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
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