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Difficulty: MediumPharmacological Therapies

While conducting hourly rounds, a practical nurse observes a client who is receiving an intravenous infusion of vancomycin for a severe bacterial infection. The infusion was initiated by the registered nurse twenty minutes ago. The client suddenly reports feeling extremely dizzy. The practical nurse notes a bright red, flushed appearance across the client's face, neck, and upper chest, and the client's blood pressure is 88/54 mm Hg88/54\text{ mm Hg} (decreased from a baseline of 122/76 mm Hg122/76\text{ mm Hg}). Which of the following actions is the priority for the practical nurse?

  1. Stop the intravenous vancomycin infusion immediately and notify the registered nurse.Answer
  2. B
    Obtain a full set of vital signs and document the findings in the electronic health record.
  3. C
    Reassure the client that facial flushing is a harmless, expected response to this antibiotic.
  4. D
    Prepare to independently administer a prescribed intravenous push dose of diphenhydramine.

Answer

The priority action is to immediately stop the intravenous vancomycin infusion and notify the registered nurse.
The client is experiencing Red Man syndrome, a known adverse reaction to intravenous vancomycin characterized by intense flushing, rash, and hypotension. Because this reaction can progress to severe cardiovascular collapse, the absolute priority action is to immediately stop the infusion to halt the delivery of the medication. Once the infusion is stopped, the practical nurse must promptly notify the registered nurse or health care provider, as the client will likely require fluid resuscitation or administration of an antihistamine.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a sudden onset of dizziness, severe facial/neck flushing, and significant hypotension (88/54 mm Hg88/54\text{ mm Hg}) shortly after starting an intravenous vancomycin infusion.
Recognizing the acute signs of an adverse medication reaction is the first step in clinical decision-making.
2
Identify the underlying complication.
The symptoms indicate Red Man syndrome, a potentially severe, rate-related infusion reaction associated with vancomycin.
Connecting the specific medication to the clinical manifestations determines the necessary emergency intervention.
3
Determine the priority intervention based on ABCs (Airway, Breathing, Circulation) and scope of practice.
The immediate threat to circulation (hypotension) must be halted by stopping the infusion. This action is safely within the practical nurse's scope.
Stopping the offending agent prevents further cardiovascular collapse and must precede additional assessment, documentation, or out-of-scope interventions.

Key Concept

Recognizing and prioritizing immediate interventions for adverse medication reactions (such as Red Man syndrome) within the practical nursing scope of practice.
Estimated Time:1m 0s
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Topics

Pharmacological Therapies

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