A practical nurse (PN) is assisting with the care of a client who is receiving an intermittent intravenous (IV) infusion of vancomycin. The client suddenly reports intense itching, and the PN observes a bright red rash on the client's face, neck, and upper chest. The client's blood pressure has dropped to . Which action should the PN take first?
- AContinue the infusion and document the rash and blood pressure as an expected reaction.
- BElevate the head of the bed for comfort and ask the client to rate the itching on a pain scale.
- Stop the vancomycin infusion immediately and alert the registered nurse (RN).Answer
- DPrepare to administer an intravenous push of epinephrine per the facility's anaphylaxis protocol.
Answer
The correct action is to stop the vancomycin infusion immediately and alert the registered nurse (RN).
The client is exhibiting signs of Red Man Syndrome or a severe hypersensitivity reaction to vancomycin, characterized by flushing, an upper body rash, and significant hypotension. The first and most critical action is to stop the offending infusion to prevent further circulatory compromise. The PN must then immediately notify the RN, as managing an acute, unstable client requires RN-level assessment and intervention.
Step-by-Step Solution
Key Concept
Prioritization and Scope of Practice in Adverse Medication Reactions