A nurse is caring for a client prescribed Vancomycin. Which nursing action is most appropriate regarding infusing over at least 60 minutes to prevent Red Man Syndrome and monitoring trough levels?

• 1 Slow the transfusion to 50 mL/hour, administer acetaminophen and diphenhydramine as prescribed, apply warm blankets, check vital signs every 15 minutes, and if symptoms persist, then stop the transfusion and notify the provider.
• 2 Pause the transfusion for 30 minutes, administer diphenhydramine and corticosteroids, and if the patient's symptoms resolve, restart the infusion at a slower rate while monitoring for recurrence.
• 3 STOP transfusion immediately, disconnect tubing at the IV hub, maintain IV with NS via new tubing, notify provider and blood bank, send remaining unit + tubing + new specimens back, monitor for shock/DIC/AKI, treat per protocol
• 4 Administer intravenous fluids wide open, give intravenous corticosteroids and antihistamines, continue the transfusion to maintain blood volume, and prepare to intubate if respiratory distress worsens. ✓ Correct answer

For study reference only. Always follow current clinical guidelines and your institution’s protocols.