A nurse is caring for a client who received alteplase 12 hr ago following a thrombotic stroke. The nurse should monitor the client for which of the following adverse effects?

A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:

Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.

A.While medication verification is important, this is not specific to administering an intermittent IV bolus. It is standard practice for high-alert medications, not routine antibiotics.

B. Flushing the IV site with sterile water prior to connecting the secondary infusion is not standard practice. Normal saline is typically used to maintain patency, but it is not necessary before connecting the secondary infusion.
C.To administer a secondary infusion (e.g., antibiotic), the secondary bag must be hung higher than the primary infusion. This allows gravity to prioritize the secondary infusion through the Y-site.

D. Disconnecting the primary IV infusion to connect the secondary infusion is not correct. The secondary infusion should connect to the primary line without disrupting the ongoing infusion unless otherwise indicated.