After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.
What action should the nurse take?

Inform the patient that the medication has been effective.

Review the patient’s culture and sensitivity reports.

Implement neutropenic precautions.

Assess the patient’s vital signs.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Filgrastim is a medication used to stimulate the growth of white blood cells, making patients less vulnerable to infections. If the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3 after administering five doses of filgrastim, it indicates that the medication has been effective.

Choice B rationale

Reviewing the patient’s culture and sensitivity reports is not directly related to the effect of filgrastim on white blood cell count.

Choice C rationale

Neutropenic precautions are typically implemented when a patient has a low white blood cell count. Since the patient’s white blood cell count has increased, implementing neutropenic precautions may not be necessary.

Choice D rationale

While it’s always important to monitor a patient’s vital signs, there’s no specific reason to do so just because the patient’s white blood cell count has increased after administering filgrastim.

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Correct Answer is C

Explanation

Choice A rationale

Administering a narcotic reversal drug is not the first action the nurse should take. While it’s true that the client’s symptoms could be due to opioid overdose, the nurse should first confirm the cause of the symptoms. In this case, the nurse finds four patches on the client’s body, which is unusual and could lead to an overdose. Therefore, the first action should be to remove the patches to prevent further absorption of the drug.

Choice B rationale

Applying an oxygen face mask might be necessary if the client is having difficulty breathing. However, this would not address the underlying problem if the client is experiencing an overdose from the morphine sulfate patches. The nurse should first remove the patches to stop further drug absorption.

Choice C rationale

The nurse finds four patches on the client’s body. This is unusual and could lead to an overdose. Therefore, the nurse’s first action should be to remove the patches to prevent further absorption of the drug. After removing the patches, the nurse can assess the client’s condition and provide further interventions as needed.

Choice D rationale

Monitoring the client’s blood pressure is an important nursing intervention, but it should not be the first action in this situation. The nurse has already found a potential cause for the client’s symptoms (i.e., the four morphine sulfate patches). Therefore, the first action should be to address this problem by removing the patches.

A. Monitor the client’s blood pressure. B. Assess the client’s urine output. C. Perform a bladder scan. D. Obtain the client’s daily weights.

Correct Answer is A

Explanation

Choice A rationale

Tamsulosin is an alpha-blocker that relaxes the smooth muscles of the prostate and bladder neck, improving urine flow. However, it can also cause hypotension, dizziness, and fainting as adverse effects. Therefore, monitoring blood pressure is essential for clients taking tamsulosin.

Choice B rationale

While assessing the client’s urine output is an important part of monitoring a client with benign prostatic hyperplasia, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice C rationale

Performing a bladder scan can be useful in assessing the client’s urinary retention, a common symptom of benign prostatic hyperplasia. However, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice D rationale

Obtaining the client’s daily weights can be useful in monitoring fluid balance, but it is not specifically related to monitoring for adverse reactions to tamsulosin.

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After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.What action should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with benign prostatic hyperplasia has been prescribed tamsulosin. What should the nurse do to monitor for an adverse reaction?

Correct Answer is A

Explanation

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After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.
What action should the nurse take?