A client previously developed flushing and pruritus during a rapid vancomycin infusion but had no wheezing, airway swelling, or hypotension. The next dose is due. Which plan is most appropriate?
1Administer the dose rapidly to shorten the client's exposure time and document the prior symptoms afterward.
2Verify a slower prescribed infusion rate, monitor closely, and give ordered premedication per the reaction plan.✓ Correct answer
3Continue at the original rate and administer an antihistamine only if flushing returns.
4Apply cold compresses during the infusion and omit vital-sign and airway assessment.
Explanation
The prior flushing and pruritus without airway compromise or hypotension are consistent with a vancomycin infusion reaction. For a subsequent dose, the nurse should verify the ordered slower infusion rate, monitor the client, and administer any prescribed premedication according to the reaction plan (option 2). A rapid or unchanged rate can trigger recurrence. Comfort measures do not replace airway and hemodynamic assessment.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Vancomycin infusion reaction.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideA vancomycin infusion reaction is related to infusion rate and mast-cell mediator release. Assess every reaction for anaphylaxis. After symptoms resolve, future doses may be given more slowly with monitoring and prescribed premedication when appropriate.
Vancomycin — An antibiotic commonly used for serious gram-positive infections.
Infusion Reaction — A reaction that occurs during medication administration and may be rate related.
Protocol — An approved facility process that guides clinical action.