A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?
The client had a decreased neutrophil count before the medication was administered.
The client had chemotherapy 12 hr before the medication was administered.
The vial was out of the refrigerator for 2 hr before the medication was administered.
The client reported feeling nauseous after the medication was administered.
The Correct Answer is C
A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:
Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pallor: Pallor refers to paleness of the skin and is not typically associated with an allergic reaction to penicillin G IM.
B. Dyspepsia: Dyspepsia refers to indigestion or discomfort in the upper abdomen and is not typically associated with an allergic reaction to penicillin G IM.
C. Bradycardia: Bradycardia refers to a slow heart rate and is not typically associated with an allergic reaction to penicillin G IM.
D. Urticaria: Urticaria, commonly known as hives, is a characteristic manifestation of an allergic reaction to penicillin G IM. It presents as raised, red, itchy welts on the skin.
Correct Answer is B
Explanation
A. Bruxism: Bruxism, or teeth grinding, is a potential adverse effect of citalopram but is generally less severe than confusion. While it should be monitored and reported if severe or persistent, it is not typically considered a priority adverse effect.
B. Confusion: Confusion can indicate a serious adverse reaction or complication, such as serotonin syndrome, which is a potentially life-threatening condition associated with the use of selective serotonin reuptake inhibitors (SSRIs) like citalopram. Therefore, confusion is the priority adverse effect to report to the provider.
C. Insomnia: Insomnia is a common side effect of citalopram and other SSRIs but is generally less severe than confusion. It should be monitored and reported if severe or persistent, but it is not typically considered a priority adverse effect.
D. Weight loss: Weight loss can occur as a side effect of citalopram but is generally less severe than confusion. It should be monitored and reported if excessive or rapid, but it is not typically considered a priority adverse effect.
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