Level: Foundational
Difficulty: Easy
Subtopic: Antibiotics
NCLEX: A client prescribed IV vancomycin has ordered trough level due before the next dose. The nurse notes flushing and…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A client prescribed IV vancomycin has ordered trough level due before the next dose. The nurse notes flushing and hypotension during the prior infusion. What is the priority action?
Question
A. Pause the infusion, assess the client, and notify the provider per protocol.
B. Increase the infusion rate to finish before shift change.
C. Give the next dose on schedule without reviewing levels or reactions.
D. Delegate antibiotic administration to UAP without RN assessment.
B. Increase the infusion rate to finish before shift change.
C. Give the next dose on schedule without reviewing levels or reactions.
D. Delegate antibiotic administration to UAP without RN assessment.
Rationale
Correct answer: A. Pause the infusion, assess the client, and notify the provider per protocol.
Rationale: Infusion reaction and timing of trough levels require RN assessment and provider communication before continuing vancomycin.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Infusion reaction and timing of trough levels require RN assessment and provider communication before continuing vancomycin.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.