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/mm³ before the medication was administered.

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

The client had chemotherapy 12 hr before the medication was administered.

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

Answer and Explanation

The Correct Answer is D

A. The client's absolute neutrophil count was 2.500/mm³ before the medication was administered:
Incorrect Explanation: This is a normal data point that does not suggest an adverse event or error.
Explanation: An absolute neutrophil count of 2.500/mm³ is within the normal range, and there is no indication of a problem related to the administration of filgrastim based on this information.
B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered:
Incorrect Explanation: Routine flushing of the IV line with appropriate solutions is a standard practice and not indicative of an incident.
Explanation: Flushing the IV line with dextrose 5% in water before and after medication administration is a routine procedure to maintain line patency and prevent interactions between medications.
C. The client had chemotherapy 12 hours before the medication was administered:
Incorrect Explanation: The timing of chemotherapy does not necessarily indicate an incident.
Explanation: Knowing the timing of chemotherapy is important for overall patient care, but it doesn't necessarily indicate an incident or error related to the administration of filgrastim.
D. The medication vial sat at room temperature for 2 hours before it was administered:
Correct Answer: This is the data point that should lead to filing an incident report.
Explanation: Many medications, including filgrastim, have specific storage requirements to ensure their effectiveness and safety. Allowing a medication vial to sit at room temperature for an extended period can compromise its stability and effectiveness. This situation should be reported as it involves a potential deviation from proper medication storage and handling procedures.

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Correct Answer is B

Explanation

A. Obtain the client's HDL level.
Explanation: This choice is not relevant to the situation. HDL (High-Density Lipoprotein) level is related to cholesterol levels and cardiovascular health, which is not directly affected by the administration of metformin instead of metoprolol.
B. Check the client's glucose level.
Explanation: Correct Choice. Metformin is an oral antidiabetic medication commonly used to lower blood glucose levels in individuals with type 2 diabetes. It works by improving insulin sensitivity and decreasing glucose production in the liver. Accidentally administering metformin instead of metoprolol could lead to hypoglycemia (low blood sugar) or other adverse effects related to glucose levels. Checking the client's glucose level is essential to assess and address any potential issues arising from this medication error.
C. Monitor the client's thyroid function levels.
Explanation: This choice is not directly relevant to the situation. Metformin and metoprolol do not significantly affect thyroid function levels. Thyroid function monitoring would not be the immediate concern in this scenario.
D. Collect the client's uric acid level.
Explanation: This choice is not directly relevant to the situation. Metformin and metoprolol do not have a primary impact on uric acid levels. Collecting the uric acid level would not be a priority in this context.

A. Slow the infusion rate. B. Apply pressure to the IV site. C. Elevate the extremity. D. Flush the IV catheter.

Correct Answer is B

Explanation

A. Slow the infusion rate:
Incorrect Explanation: Slowing the infusion rate is not the appropriate action when fluid infiltration has occurred.
Explanation: Fluid infiltration occurs when the IV catheter becomes dislodged from the vein and fluid enters the surrounding tissues. Slowing the infusion rate will not prevent or address this issue.
B. Apply pressure to the IV site:
Correct Answer: Applying pressure to the IV site is an appropriate initial action when fluid infiltration occurs.
Explanation: Applying gentle pressure just above the insertion site can help prevent further fluid from entering the surrounding tissues. This can help minimize the extent of infiltration and reduce potential complications.
C. Elevate the extremity:
Incorrect Explanation: Elevating the extremity is not the primary action to take when fluid infiltration is present.
Explanation: Elevating the extremity might be helpful in reducing swelling and promoting blood flow in general, but it's not the primary action to address fluid infiltration.
D. Flush the IV catheter:
Incorrect Explanation: Flushing the IV catheter is not the appropriate action for addressing fluid infiltration.
Explanation: Flushing the catheter might exacerbate the infiltration by pushing more fluid into the surrounding tissues. It's important to address the issue of infiltration first.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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