The nurse notes a client that has received intravenous vancomycin (Vancocin) develops an upper body rash and has a decreased urine output. In addition to notifying the healthcare provider, which is the nurse's priority action?

Question

Quizplus · Accepted Answer

The client's symptoms suggest an allergic reaction or nephrotoxicity related to vancomycin, and holding the next dose would be the most appropriate action to prevent further harm. Obtaining a sterile urine specimen and notifying the healthcare provider are also important, but holding the medication takes priority as it can potentially worsen the client's condition. Obtaining a stat x-ray and administering an antihistamine are not indicated or relevant to the client's symptoms.

The Nurse Notes a Client That Has Received Intravenous Vancomycin