A 75-year-old client receives vancomycin for MRSA pneumonia. Day 5 labs show creatinine rising from 1.0 to 1.7 mg/dL, urine output decreased to 0.4 mL/kg/h, vancomycin trough is 25 mg/L, and the client also receives gentamicin and IV contrast yesterday. Which is the priority nursing action?

Vancomycin can cause acute kidney injury, particularly with troughs above 15 to 20 mg/L, prolonged courses (more than 7 days), pre-existing renal impairment, advanced age, hypovolemia, and concurrent nephrotoxins (aminoglycosides, IV contrast, NSAIDs, ACE inhibitors, ARBs, loop diuretics, piperacillin-tazobactam in some studies). The pattern in this scenario — elderly client, rising creatinine, oliguria, supratherapeutic trough 25 mg/L, gentamicin co-administration, recent contrast — strongly suggests vancomycin-associated AKI. Standard nursing response: (1) hold the next dose and contact the prescriber, (2) anticipate dose hold or reduction, repeat creatinine and trough, possible AUC-guided redosing or alternate agent (linezolid, daptomycin) for MRSA, (3) strict intake and output, daily weight, monitor for fluid overload and electrolyte imbalance, (4) review and minimize concurrent nephrotoxins (hold NSAIDs and ACEi/ARBs if possible, weigh contrast indications, hold or reduce gentamicin per ID input), (5) ototoxicity evaluation — hearing changes, tinnitus, vertigo, balance — because vancomycin can cause auditory and vestibular toxicity especially with high troughs, (6) ensure adequate hydration unless contraindicated. Continuing the same dose, increasing the dose, and adding an NSAID are unsafe and worsen the kidney injury.

Hold and notify, dose adjust, minimize nephrotoxins, watch for ototoxicity. Vancomycin AKI is a high-yield NCLEX safety topic.