The physician has prescribed epoetin alfa (Epogen) for the client. What is the priority assessment by the nurse?
1. The client's blood pressure
2. The client's report of a headache, indicating a stroke
3. The client's ability to use the proper injection techniques for self-administration
4. The client's hemoglobin and hematocrit levels
Correct Answer: 1
Rationale 1: The most serious adverse effect of epoetin alfa (Epogen) is hypertension, which can raise blood pressure to dangerous levels, and which occurs in as many as 30% of clients receiving the drug.
Rationale 2: Clients are at risk for a stroke, but this is a complication of uncontrolled hypertension; blood pressure assessment is a priority.
Rationale 3: Assessment of hypertension takes precedence over injection techniques.
Rationale 4: Hemoglobin and hematocrit levels should be assessed, but they are not as high a priority as blood pressure.
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