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 A
Explanation
A. Asking the adolescent to describe the quality of their pain can provide valuable information about the characteristics of the pain, such as sharp, dull, throbbing, or burning.
B. Asking the adolescent to point to the area of most severe pain assesses location, not quality.
C. Asking about pain level assesses intensity, not quality.
D. Asking about the timing of pain increasing assesses onset, not quality.
Correct Answer is C
Explanation
A. Orange juice is not typically restricted with phenelzine use.
B. Sweet potatoes are not typically restricted with phenelzine use.
C. Cheddar cheese contains tyramine, which can cause a hypertensive crisis when consumed with phenelzine, a monoamine oxidase inhibitor (MAOI).
D. Canned tuna is not typically restricted with phenelzine use.
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