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.

Answer and Explanation

The Correct Answer is D

The correct answer is d

Choice A reason:

Administering filgrastim 12 hours after chemotherapy does not typically require an incident report. Filgrastim is often given at least 24 hours after chemotherapy to avoid the risk of increasing the toxicity of the chemotherapy agents. While the timing is closer than recommended, it does not necessarily constitute an error unless specific instructions for the timing were provided by the prescribing physician.

Choice B reason:

The medication vial sitting at room temperature for 2 hours before administration does not require an incident report. Filgrastim can be left out at room temperature for up to 24 hours before use. This is within the safe handling guidelines for the medication.

Choice C reason:

An absolute neutrophil count (ANC) of 2,500/mm³ is within the normal range, which is typically 1,500-8,000/mm³. Filgrastim is used to increase neutrophil counts in patients with low ANC due to chemotherapy. Since the ANC was not low before administration, this would not necessitate an incident report, although it may prompt a review of the necessity of the medication.

Choice D reason:

Flushing the client's IV line with dextrose 5% in water before and after the medication was administered is not the standard procedure and could potentially lead to medication errors or adverse effects. Filgrastim should be diluted in glucose 5% in water for intravenous infusion, but not used to flush the line. This deviation from the standard protocol is what necessitates an incident report.

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Correct Answer is D

Explanation

Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.

Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.

Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.

Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.

Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.

Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.

A. Administer epinephrine IM. B. Replace the infusion with 0.9% sodium chloride. C. Give diphenhydramine IM. D. Elevate the clients legs and feet.

Correct Answer is A

Explanation

Epinephrine (adrenaline) is the first-line treatment for anaphylaxis, a severe and potentially life-threatening allergic reaction. Epinephrine works by reducing the body’s allergic response and improving the breathing and circulation of the client. Epinephrine should be given as soon as possible after the onset of anaphylaxis symptoms, using an auto-injector device if available.

Choice B is wrong because replacing the infusion with 0.9% sodium chloride (normal saline) is not enough to treat anaphylaxis. Normal saline can help maintain the blood pressure and hydration of the client, but it does not reverse the allergic reaction or improve the breathing of the client. Normal saline can be given after epinephrine, but not before or instead of it.

Choice C is wrong because giving diphenhydramine IM is not enough to treat anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some of the symptoms of anaphylaxis, such as itching and hives, but it works too slowly and does not address the more serious effects of anaphylaxis on the breathing and circulation of the client. Diphenhydramine can be given after epinephrine, but not before or instead of it.

Choice D is wrong because elevating the client's legs and feet is not enough to treat anaphylaxis. Elevating the legs and feet can help increase the blood flow to the vital organs, but it does not reverse the allergic reaction or improve the breathing of the client. Elevating the legs and feet can be done after epinephrine, but not before or instead of it.

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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?

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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?