Shortly after an IV vancomycin infusion begins, a client develops diffuse flushing and pruritus of the face, neck, and upper torso. Blood pressure is stable, and there is no wheezing or stridor. Which action should the nurse take first?
1Administer intramuscular epinephrine and continue the infusion at the prescribed rate
2Stop the infusion, assess the client, and notify the prescribing clinician✓ Correct answer
3Increase the infusion rate so the remaining medication is delivered more quickly
4Remove the IV catheter and record vancomycin as a permanent allergy
Explanation
Flushing and pruritus without airway compromise or hypotension suggest a vancomycin infusion reaction. Stop the infusion, reassess airway and circulation, and notify the clinician. A slower restart and antihistamine may be prescribed after symptoms resolve.
Quick answer Stop vancomycin, assess the client, and notify the prescribing clinician. The stable blood pressure and absent wheezing or stridor support an infusion reaction, but airway and circulation still require immediate reassessment.
Why this is correct Vancomycin can trigger a rate-related histamine response with flushing and itching. Stopping the infusion prevents additional exposure while the nurse determines whether the reaction remains limited or is progressing toward a more dangerous allergic response.
Easy analogy or mental picture Think of the infusion as a faucet filling a basin too quickly. Turning off the faucet is the first move while checking whether water has only splashed or is overflowing; the analogy does not replace ongoing assessment for anaphylaxis.
Memory hook Flushing during vancomycin means stop the flow, check airway and circulation, then clarify the restart plan.
NCLEX decision rule When an infusion reaction appears, stop the suspected infusion before adding more medication. Distinguish stable flushing and itching from hypotension, bronchospasm, stridor, or swelling that would require emergency anaphylaxis treatment.
Why the other choices are wrong Epinephrine is reserved for findings suggesting anaphylaxis and the triggering infusion should not continue. Increasing the rate worsens a rate-related reaction, while removing the IV and labeling a permanent allergy before assessment can eliminate needed access and misclassify the event.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
FDA: Vancomycin Injection Prescribing InformationU.S. Food and Drug Administration