A nurse is assessing a client who is taking disulfiram and consumed alcohol. Which of the following findings is the priority for the nurse to report to the provider?

Hyperkalemiais a critical electrolyte disturbance defined by a serum potassium level exceeding 5.0 mEq/L, which alters the resting membrane potentialof excitable tissues. This condition often results from renal failure, metabolic acidosis, or cellular injury, leading to cardiac dysrhythmiasand neuromuscular weakness. Clinical management involves stabilizing the myocardium, shifting potassium intracellularly, and facilitating the definitive excretionof the excess cation from the body to prevent cardiac arrest.

Rationale:

Administering sodium polystyrenerectally is appropriateas it acts as a cation-exchange resin to remove excess potassium from the body. It works in the large intestine by exchanging sodium ions for potassium ions, which are then excreted through the feces. This provides a definitive method for lowering the total body potassiumload in a client with a serum level of 6 mEq/L.

Administering potassium chloride IV is inappropriateand life-threatening for this client because their serum potassium level is already critically elevated at 6 mEq/L. Adding more exogenous potassium would exacerbate the hyperkalemic state, leading to worsening cardiac conduction delays or ventricular fibrillation. The primary goal for this client is potassium reduction, not supplementation or replacement.

Administering insulin IVis appropriatebecause it stimulates the sodium-potassium ATPase pump, facilitating the rapid shift of potassium from the extracellular fluid into the intracellular compartment. This provides a temporary but life-saving reduction in serum potassium levels. Intravenous dextrose is typically co-administered to prevent hypoglycemiaunless the client’s blood glucose is already significantly elevated.

Administering hydralazine IVis inappropriatebecause this client is already experiencing low blood pressure, with a reading of 98/54 mm Hg at 1100. Hydralazine is a direct-acting vasodilatorused to treat hypertension by relaxing vascular smooth muscle. Giving a vasodilator to a hypotensive client would lead to severe hemodynamic collapse and further compromise organ perfusion.

Administering calcium gluconate IVis appropriateas a first-line emergency intervention to stabilize the myocardial cell membrane. While calcium does not lower the serum potassium level, it antagonizes the cardiotoxic effects of hyperkalemia by increasing the threshold potential. This helps prevent lethal arrhythmias, such as the progression from the current peaked T waves to sinusoidal rhythmsor asystole.

Filgrastim is a granulocyte colony-stimulating factor(G-CSF) used to stimulate the production of neutrophilsand reduce the duration of neutropenia. It acts on hematopoietic cells to increase phagocytic activity, but its timing relative to cytotoxic chemotherapy is critical to prevent drug interaction.

Rationale:

A.A decreased neutrophil count is the primary indication for administering filgrastim, not a reason for an incident report. The medication is specifically intended to treat or prevent febrile neutropenia in clients undergoing myelosuppressive therapy. Finding a low absolute neutrophil count justifies the use of the growth factor to boost the client's immune defense.

B.Filgrastim vials are stable at room temperature for up to 24 hours depending on specific manufacturer guidelines. Leaving the vial out for only 2 hours does not compromise the integrity of the medication or constitute a medication error. Therefore, this action does not necessitate an incident report as the medication remains safe for administration to the client.

C.Filgrastim should not be administered within 24 hours before or after the administration of cytotoxic chemotherapy. Giving the medication only 12 hr after chemotherapy is a significant timing error that can interfere with the effectiveness of the treatment and worsen marrow suppression. The nurse must complete an incident report to document this violation of the safety protocol for colony-stimulating factors.

D.Nausea is a common side effect of chemotherapy and can also occur with filgrastim, though it is not a reason for an incident report. Incident reports are reserved for errors, accidents, or unexpected hazardous events, not for documenting known, documented adverse reactions. The nurse should manage the nausea with antiemetics rather than filing an administrative error report.