A nurse is caring for a client who has a respiratory infection and is receiving an antibiotic. Which of the following medications puts the client at risk for developing hearing loss?

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.

Mixing different types of insulinrequires a specific sequence to prevent cross-contaminationof vials. Regular insulin is short-acting and must remain pure, while NPH is an intermediate-acting isophanesuspension containing protamine. Correct technique ensures that the rapid onset of regular insulin is not compromised by the longer-acting NPH components.

Rationale:

A.Injecting air into the regular insulin vial first is the incorrect order for the air-injection phase of mixing. The nurse should first inject air into the NPH (cloudy) vial without touching the solution, then inject air into the regular (clear) vial. This sequence maintains the pressure in both vials while ensuring the clear insulin remains completely uncontaminated by protamine.

B.Shaking insulin vials vigorously is contraindicated because it creates air bubbles that can lead to inaccurate dosing and may denature the protein molecules. Instead, the nurse should gently roll the NPH vial between the palms to re-suspend the particles. Regular insulin does not require agitation as it is a clear solution that does not settle or separate.

C.Ensuring that NPH has a clear appearance is incorrect because NPH is a suspension that should normally appear cloudy or milky after gentle agitation. If NPH appears clear, it may have lost its potency or been mislabeled. Conversely, regular insulin must always be clear; any cloudiness in a regular insulin vial indicates contamination or expiration.

D.Withdrawing the regular insulin into the syringe first is the correct procedure after air has been injected into both vials. This "clear to cloudy" method ensures that no NPH insulin enters the regular insulin vial. If protamine from the NPH were introduced into the regular insulin, it would alter the drug's rapid-acting pharmacokinetics, potentially leading to unpredictable glycemic control.