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 D

Explanation

A. "If my pain is not relieved in 20 minutes, I will take a second tablet." Sublingual nitroglycerin should be taken at 5-minute intervals, up to a maximum of three doses within 15 minutes. If chest pain persists after three doses, emergency medical assistance is necessary, as this may indicate a myocardial infarction. Delaying a second dose for 20 minutes may lead to worsening of the condition and delay appropriate treatment.

B. "I will keep my tablets on a shelf in the bathroom." Nitroglycerin is highly sensitive to heat, light, and moisture, which can cause it to lose potency. Storing it in the bathroom, where temperature and humidity fluctuate, can degrade the medication. It should be kept in its original dark glass container with the lid tightly closed and stored in a cool, dry place away from moisture and heat sources.

C. "I should be sure to swallow the tablet whole." Sublingual nitroglycerin is designed to dissolve under the tongue for rapid absorption into the bloodstream. Swallowing it whole delays its effect because it would need to pass through the digestive system before being absorbed, reducing its ability to quickly relieve angina. Clients should be instructed to place the tablet under the tongue and allow it to dissolve completely without chewing or swallowing.

D. “If my mouth is dry, I will take a sip of water before I take the tablet.” A dry mouth can slow the dissolution of the sublingual tablet, delaying its absorption and effectiveness. Taking a sip of water before administration ensures the tablet dissolves properly under the tongue, allowing for rapid relief of angina symptoms. However, clients should avoid drinking excessive amounts of water that might wash the tablet down before it dissolves.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Blood pressure. The client's blood pressure dropped from 104/56 mm Hg to 80/46 mm Hg, indicating worsening hypotension. This suggests fluid volume depletion due to ongoing diarrhea and possible sepsis from Clostridium difficile infection. Hypotension is the priority concern as it can lead to shock and organ dysfunction if not addressed immediately. The nurse should anticipate fluid resuscitation with IV fluids to restore circulatory volume.
Hgb level. The client's hemoglobin is 17 g/dL, which is elevated compared to normal values (12-16 g/dL). This suggests hemoconcentration, likely due to dehydration from severe diarrhea rather than an actual increase in red blood cell count. While this is concerning, the immediate priority is addressing hypotension before evaluating hemoglobin further.
Temperature. The client has a persistent fever of 38.9°C (102°F), which indicates an active Clostridium difficile infection. While fever management is important, hypotension takes priority because it can lead to hypoperfusion and organ failure. Antipyretic medications and infection control measures can be initiated after stabilizing blood pressure.
Potassium level. The client's potassium is 3.1 mEq/L, which is below the normal range (3.5-5.0 mEq/L). Diarrhea leads to potassium loss, increasing the risk of cardiac arrhythmias and muscle weakness. After stabilizing the client’s blood pressure, potassium replacement is critical to prevent life-threatening hypokalemia-related complications such as cardiac dysrhythmias.
Abdominal findings. The client has a soft, distended abdomen with hyperactive bowel sounds and watery stools with mucus, consistent with Clostridium difficile infection. While these findings confirm the diagnosis, the more urgent issues of hypotension and electrolyte imbalances must be addressed first before further gastrointestinal assessment.
Hct level. The hematocrit is elevated (48%), which aligns with hemoconcentration from dehydration. However, fluid resuscitation will help correct this, making it a secondary concern after addressing blood pressure and potassium levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has angina and a new prescription of nitroglycerin sublingual. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assisting in the care of a female client. Complete the following sentence by using the lists of options. The nurse should first address the client ....... followed by the client's ......

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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