A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse file an incident report?

The client's absolute neutrophil count was 2.500/mm before the medication was administered

The nurse flushed the client's (V line with dextrose 5% in water before and after the medication was administered

The medication vial sat at room temperature for 2 hr before it was administered

The client had chemotherapy 12 hr before the medication was administered

Answer and Explanation

The Correct Answer is C

A. The client's absolute neutrophil count was 2.500/mm before the medication was administered:
This information does not indicate an error in the administration process. The absolute neutrophil count being 2.500/mm before the medication was given is relevant to the client's condition but does not suggest an incident related to the administration of filgrastim.
B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered:
Flushing the IV line with dextrose 5% in water is a standard practice before and after medication administration. This action helps ensure that the medication is effectively delivered and that the line remains patent. There is no indication of an error in this case.
C. The medication vial sat at room temperature for 2 hr before it was administered:
Filgrastim is a medication that typically requires refrigeration to maintain stability. Allowing it to sit at room temperature for an extended period can affect its efficacy and safety. This is a deviation from the recommended storage conditions and should be reported as an incident to assess potential consequences.
D. The client had chemotherapy 12 hr before the medication was administered:
This information does not necessarily suggest an incident related to the administration of filgrastim. The timing of chemotherapy is an essential consideration in cancer treatment protocols. Filgrastim is often administered to support recovery from the hematopoietic effects of chemotherapy.

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Correct Answer is D

Explanation

A. Infiltration:
Infiltration refers to the inadvertent administration of a non-vesicant solution into the surrounding tissue. It is characterized by swelling, pallor, and coolness at the infusion site, but redness and inflammation along the vein are not typical signs of infiltration.
B. Extravasation:
Extravasation occurs when a vesicant solution (a substance that can cause tissue damage) infiltrates into the surrounding tissue. It can cause tissue damage and necrosis. While inflammation is a concern with extravasation, it is not the primary sign, and redness may occur later.
C. Venous spasm:
Venous spasm involves the constriction of the blood vessel, leading to decreased blood flow. It is not typically associated with redness and inflammation along the vein.
D. Phlebitis:
This is the correct answer. Phlebitis refers to inflammation of a vein, and it is characterized by redness, warmth, and tenderness along the course of the vein. Phlebitis can be caused by various factors, including irritants in the infused solution, mechanical trauma, or infection.

A. Nitroglycerin B. Albuterol C. Furosemide D. Indomethacin

Correct Answer is A

Explanation

A. Nitroglycerin: Contraindicated with sildenafil due to the risk of severe hypotension. Both medications cause vasodilation, and their combined use can result in a dangerous drop in blood pressure.
B. Albuterol: Albuterol is not a contraindication for sildenafil. It is a bronchodilator used to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD).
C. Furosemide: Furosemide is a diuretic and is not a contraindication for sildenafil. However, it is important to consider the overall health and medical conditions of the individual.
D. Indomethacin: Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) and is not a contraindication for sildenafil. However, individuals taking NSAIDs should be cautious due to potential interactions and side effects.

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A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse file an incident report?

Nursing Test Bank

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Correct Answer is D

Explanation

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