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 nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered.
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 Correct Answer is D
A. The client's absolute neutrophil count was 2.500/mm³ before the medication was administered:
Incorrect Explanation: This is a normal data point that does not suggest an adverse event or error.
Explanation: An absolute neutrophil count of 2.500/mm³ is within the normal range, and there is no indication of a problem related to the administration of filgrastim based on this information.
B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered:
Incorrect Explanation: Routine flushing of the IV line with appropriate solutions is a standard practice and not indicative of an incident.
Explanation: Flushing the IV line with dextrose 5% in water before and after medication administration is a routine procedure to maintain line patency and prevent interactions between medications.
C. The client had chemotherapy 12 hours before the medication was administered:
Incorrect Explanation: The timing of chemotherapy does not necessarily indicate an incident.
Explanation: Knowing the timing of chemotherapy is important for overall patient care, but it doesn't necessarily indicate an incident or error related to the administration of filgrastim.
D. The medication vial sat at room temperature for 2 hours before it was administered:
Correct Answer: This is the data point that should lead to filing an incident report.
Explanation: Many medications, including filgrastim, have specific storage requirements to ensure their effectiveness and safety. Allowing a medication vial to sit at room temperature for an extended period can compromise its stability and effectiveness. This situation should be reported as it involves a potential deviation from proper medication storage and handling procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Keep the tablets at room temperature in their original glass bottle." This is a correct storage instruction. Nitroglycerin tablets are sensitive to heat and light, so they should be stored in their original container, protected from light, and kept at room temperature.
B. "Discard any tablets you do not use every 6 months." This is not an accurate instruction. Nitroglycerin tablets usually have an expiration date printed on the label, and they should be discarded after that date.
C. "Take one tablet each morning 30 minutes prior to eating." This is not an accurate instruction. Sublingual nitroglycerin is taken as needed to relieve angina symptoms, not on a regular schedule like a daily medication.
D. "Place the tablet between your cheek and gum to dissolve."
Sublingual nitroglycerin tablets are used to relieve angina symptoms by causing vasodilation, which increases blood flow to the heart muscle. To take sublingual nitroglycerin tablets effectively, the client should be instructed to place the tablet between the cheek and gum to dissolve. This allows the medication to be absorbed through the mucous membranes in the mouth and enter the bloodstream quickly, providing rapid relief from angina symptoms.
Correct Answer is A
Explanation
A. For assessing pain in a 4-year-old child following an orthopedic procedure, the nurse should use the FACES pain scale.
The FACES pain scale uses a series of faces with varying expressions, from smiling to crying, to help children express their level of pain. Children are asked to point to the face that best matches how they feel. This scale is particularly useful for young children who may not have the verbal skills to describe their pain accurately using words or numbers.
B. Word-graphic
Explanation: The word-graphic pain scale typically uses a combination of words and drawings to assess pain, making it more suitable for children who are slightly older and can understand simple words and concepts.
C. Numeric
Explanation: The numeric pain scale involves asking the child to rate their pain on a scale from 0 to 10. This scale is more appropriate for older children who can understand and assign numerical values to their pain intensity.
D. CRIES
Explanation: The CRIES pain scale is often used for assessing pain in newborns and infants up to 6 months old. It focuses on crying, oxygen saturation, vital signs, and facial expressions.
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