A nurse is assessing a client who has asthma and a prescription for albuterol. The nurse should monitor the client for which of the following adverse effects?

The correct answer is Choice B.

Choice A rationale:

Documenting the administration of the medication is crucial for maintaining accurate records and ensuring accountability. However, it is not the first action to take. The priority is to ensure the correct patient receives the correct medication.

Choice B rationale:

Identifying the client using two identifiers is the first and most critical step. This action ensures that the right patient receives the right medication, thereby minimizing the risk of medication errors.

Choice C rationale:

Comparing the amount of medication available to the inventory record is important for maintaining accurate inventory and preventing misuse or theft of controlled substances. However, this is not the first step in the process of administering medication to a patient in pain.

Choice D rationale:

Removing the medication from the medication dispensing cabinet is part of the process, but it should only be done after the patient has been properly identified to avoid any potential errors.

Choice A rationale: Administering filgrastim after chemotherapy is a standard practice to boost white blood cell count. However, filgrastim should not be given within 24 hours before or after chemotherapy, as it can affect the efficacy and increase the risk of side effects. Administering the medication 12 hours after chemotherapy falls within this contraindicated window, necessitating an incident report.

Choice B rationale: Filgrastim can be stored at room temperature for short periods, and 2 hours is generally within acceptable limits for stability.

Choice C rationale: An absolute neutrophil count of 2,500/mm³ is within the normal range, and there is no contraindication for administering filgrastim.

Choice D rationale: Flushing the client's IV line with dextrose 5% in water before and after administering filgrastim is not appropriate, as this medication is typically administered with saline solution. Using an incorrect flushing solution could affect the medication's efficacy or compatibility, necessitating an incident report.