A nurse is caring for a client who is receiving filgrastim. The nurse should monitor the client for which of the following adverse effects?

Hypertension

Fluid retention

Bone pain

Hypokalemia

Answer and Explanation

The Correct Answer is C

A. Hypertension. Filgrastim, a granulocyte colony-stimulating factor (G-CSF), primarily stimulates white blood cell production. While minor blood pressure fluctuations can occur, hypertension is not a common or significant adverse effect. Monitoring blood pressure is important, but sustained hypertension is not expected.

B. Fluid retention. Filgrastim does not typically cause significant fluid retention. Medications such as corticosteroids or certain chemotherapeutic agents are more likely to lead to fluid overload. While rare cases of capillary leak syndrome have been reported, general fluid retention is not a primary concern.

C. Bone pain. Bone pain is the most common adverse effect of filgrastim. The medication stimulates bone marrow activity, leading to increased production of neutrophils, which can cause discomfort in bones, particularly in long bones such as the femur and sternum. Pain is usually mild to moderate and can be managed with acetaminophen or NSAIDs if appropriate.

D. Hypokalemia. Filgrastim does not have a direct effect on potassium levels. Electrolyte imbalances are more commonly associated with diuretics, corticosteroids, or chemotherapy. Clients on filgrastim typically do not require routine potassium monitoring unless other risk factors are present.

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Correct Answer is A

Explanation

A. Baker's yeast. The hepatitis B vaccine is contraindicated in individuals with a severe allergy to baker’s yeast. This is because the vaccine is produced using Saccharomyces cerevisiae (baker’s yeast), which can trigger an allergic reaction in susceptible individuals. Symptoms of a yeast allergy may include rash, difficulty breathing, and anaphylaxis, requiring the vaccine to be withheld and an alternative plan considered.

B. Nuts. Nut allergies are not related to the hepatitis B vaccine, as it does not contain nut-derived ingredients. While nut allergies can be severe and cause anaphylaxis, they do not pose a specific risk in the administration of this vaccine. Therefore, the presence of a nut allergy alone does not require withholding the immunization.

C. Wheat. A wheat allergy is not a contraindication for the hepatitis B vaccine. Wheat allergies primarily cause reactions to gluten-containing foods or products but do not have any connection to the components used in the production of the vaccine. The vaccine can be safely administered to individuals with wheat allergies.

D. Egg yolk. While some vaccines, such as the influenza vaccine, may be derived from egg proteins, the hepatitis B vaccine is not produced using egg-based components. An allergy to egg yolk does not pose a risk for adverse reactions to this vaccine, so it should not be withheld in individuals with an egg allergy.

A. Assist the client to a left lateral position. B. Insert the suppository along the posterior wall of the vaginal canal C. Apply a light coating of petroleum jelly to the suppository. D. Put on sterile gloves before handling the suppository.

Correct Answer is B

Explanation

A. Assist the client to a left lateral position. The preferred position for vaginal suppository insertion is the dorsal recumbent (lying on the back with knees bent) or the lithotomy position. The left lateral position is typically used for rectal suppository administration, not vaginal medication insertion.

B. Insert the suppository along the posterior wall of the vaginal canal. The suppository should be inserted along the posterior vaginal wall, as this allows for proper absorption and helps ensure the medication remains in place. The client should be advised to lie down for at least 10-15 minutes after insertion to prevent the suppository from slipping out.

C. Apply a light coating of petroleum jelly to the suppository. Petroleum jelly should never be used as it can interfere with medication absorption and may break down the suppository. If lubrication is needed, a small amount of water-soluble lubricant (e.g., KY Jelly) can be applied to facilitate insertion.

D. Put on sterile gloves before handling the suppository. Clean gloves (not sterile gloves) are sufficient for vaginal suppository administration. The vaginal canal is not a sterile environment, so strict aseptic technique is not required. However, proper hand hygiene and glove use are essential to prevent contamination and infection.

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A nurse is caring for a client who is receiving filgrastim. The nurse should monitor the client for which of the following adverse effects?

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