A nurse is caring for a client who is receiving filgrastim. The nurse should monitor the client for which of the following adverse effects?

• Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
• Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
• Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
• Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
• Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
• Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
• Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

A. Lower the head of the client's bed. There is no need to lower the client’s head of the bed in response to receiving glipizide instead of guaifenesin. Glipizide is an oral antidiabetic medication used to lower blood glucose, while guaifenesin is an expectorant for respiratory conditions. Lowering the head of the bed does not address the potential effects of receiving the wrong medication.

B. Check the client for urinary retention. Glipizide does not cause urinary retention. Instead, it stimulates insulin release to lower blood sugar. If hypoglycemia occurs due to an unintentional dose of glipizide, symptoms such as sweating, dizziness, confusion, or tremors are more concerning than bladder dysfunction.

C. Offer the client a carbohydrate snack. Since glipizide lowers blood glucose levels, administering it instead of guaifenesin could result in hypoglycemia, particularly in a client who does not have diabetes. The nurse should monitor for signs of low blood sugar, such as shakiness, confusion, diaphoresis, and dizziness, and provide a fast-acting carbohydrate (e.g., juice, crackers, or glucose tablets) if symptoms develop.

D. Test the client’s deep-tendon reflexes. Glipizide does not affect neuromuscular function or deep-tendon reflexes. While severe hypoglycemia can cause altered mental status or seizures, routine reflex testing is not necessary for monitoring the effects of an incorrect glipizide administration.