Difficulty: Medium
Average Score: 90%
Simulated
A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the client experiencing a vancomycin infusion reaction?
Correct answer
B
Rationale
Correct Answer: B. The client experiencing hypotension indicates a possible vancomycin infusion reaction. Vancomycin is known to cause hypotension as a side effect, which could be a sign of an adverse reaction. Hypotension can be a symptom of anaphylaxis or "red man syndrome" associated with vancomycin infusion. Monitoring for hypotension is crucial during vancomycin administration.
Incorrect choices:
A: The client having an increased creatinine level is not typically associated with vancomycin infusion reactions. This finding may indicate kidney damage but is not specific to a vancomycin reaction.
C: Red and edematous IV site suggests local inflammation or infection at the IV site, not necessarily related to vancomycin infusion.
D: Ringing in the ears is a symptom of ototoxicity, a known side effect of vancomycin, but not specific to an infusion reaction.
Incorrect choices:
A: The client having an increased creatinine level is not typically associated with vancomycin infusion reactions. This finding may indicate kidney damage but is not specific to a vancomycin reaction.
C: Red and edematous IV site suggests local inflammation or infection at the IV site, not necessarily related to vancomycin infusion.
D: Ringing in the ears is a symptom of ototoxicity, a known side effect of vancomycin, but not specific to an infusion reaction.