NCLEX-RN (Registered Nurse) Practice Exam · Question
A client is receiving IV vancomycin. The nurse notes flushing and a rash on the client's upper body. What is the nurse's priority action?
This describes 'Red Man Syndrome,' common with rapid vancomycin infusion. Slowing the rate is the immediate intervention.
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Question: A client is receiving IV vancomycin. The nurse notes flushing and a rash on the client's upper body. What is the nurse's priority action?
Answer options:
- Discontinue the IV infusion immediately. ✅ Slow down the rate of the vancomycin infusion.
- Administer an antihistamine as ordered.
- Notify the primary healthcare provider.
Correct answer: Slow down the rate of the vancomycin infusion.
Explanation: This describes 'Red Man Syndrome,' common with rapid vancomycin infusion. Slowing the rate is the immediate intervention.
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