After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.
What action should the nurse take?

Inform the patient that the medication has been effective.

Review the patient’s culture and sensitivity reports.

Implement neutropenic precautions.

Assess the patient’s vital signs.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Filgrastim is a medication used to stimulate the growth of white blood cells, making patients less vulnerable to infections. If the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3 after administering five doses of filgrastim, it indicates that the medication has been effective.

Choice B rationale

Reviewing the patient’s culture and sensitivity reports is not directly related to the effect of filgrastim on white blood cell count.

Choice C rationale

Neutropenic precautions are typically implemented when a patient has a low white blood cell count. Since the patient’s white blood cell count has increased, implementing neutropenic precautions may not be necessary.

Choice D rationale

While it’s always important to monitor a patient’s vital signs, there’s no specific reason to do so just because the patient’s white blood cell count has increased after administering filgrastim.

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Correct Answer is A

Explanation

Choice A rationale

Tamsulosin is an alpha-blocker that relaxes the smooth muscles of the prostate and bladder neck, improving urine flow. However, it can also cause hypotension, dizziness, and fainting as adverse effects. Therefore, monitoring blood pressure is essential for clients taking tamsulosin.

Choice B rationale

While assessing the client’s urine output is an important part of monitoring a client with benign prostatic hyperplasia, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice C rationale

Performing a bladder scan can be useful in assessing the client’s urinary retention, a common symptom of benign prostatic hyperplasia. However, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice D rationale

Obtaining the client’s daily weights can be useful in monitoring fluid balance, but it is not specifically related to monitoring for adverse reactions to tamsulosin.

A. Instruct the client to request assistance when ambulating to the bathroom. B. Administer a stool softener/laxative at the same time as the analgesic. C. Tell the client to notify the nurse if the pain is not relieved. D. Advise the client that the medication should start to work in about 30 minutes.

Correct Answer is A

Explanation

Choice A rationale

Codeine is an opioid medication that can cause drowsiness and dizziness. This can increase the risk of falls, particularly in older adults or those with balance or mobility issues. Therefore, it is important to instruct the client to request assistance when ambulating to prevent falls.

Choice B rationale

While constipation is a common side effect of opioid medications like codeine, and a stool softener or laxative may be helpful in managing this side effect, it is not the highest priority nursing action. The risk of falls due to drowsiness or dizziness is a more immediate safety concern.

Choice C rationale

While it is important for the client to notify the nurse if the pain is not relieved, this is not the highest priority nursing action. The safety of the client is the primary concern, and preventing falls by providing assistance with ambulation is a more immediate need.

Choice D rationale

Advising the client that the medication should start to work in about 30 minutes is an important part of patient education, but it is not the highest priority nursing action. The safety of the client is the primary concern, and preventing falls by providing assistance with ambulation is a more immediate need.

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After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.What action should the nurse take?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is A

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After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.
What action should the nurse take?