Question

a nurse is collecting data on a client who is receiving vancomycin iv. the nurse observes the client has a rash on their neck, chest, and back. which of the following actions should the nurse take first?
notify the client’s provider.
stop the infusion of the vancomycin.
administer diphenhydramine to the client.
document the incident in the client’s chart.

Explanation:

When a client receiving IV vancomycin develops a rash, it may indicate an allergic reaction. The first priority in such a situation is to stop the infusion of the medication (vancomycin) to prevent further exposure and potential worsening of the reaction. Notifying the provider, administering diphenhydramine, and documenting the incident are important but should follow stopping the infusion as the immediate action.

Answer:

B. Stop the infusion of the vancomycin.