# A 65-year-old hospitalized client develops severe Clostridioides difficile colitis with watery diarrhea, fever, and WBC 18,000. The prescriber orders vancomycin 125 mg PO every 6 hours for 10 days. Which nursing instruction is most appropriate? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=375224&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A 65-year-old hospitalized client develops severe Clostridioides difficile colitis with watery diarrhea, fever, and WBC 18,000. The prescriber orders vancomycin 125 mg PO every 6 hours for 10 days. Which nursing instruction is most appropriate? ## Option 1. Request a change to IV vancomycin 500 mg every 6 hours because the patient's fever and leukocytosis suggest systemic infection, and oral vancomycin does not provide adequate serum levels to treat possible bacteremia; maintain contact precautions and perform hand hygiene with alcohol-based hand rub after patient care, as alcohol is effective against most pathogens. 2. Hold the oral vancomycin as ordered and contact the prescriber to request a change to IV metronidazole 500 mg every 8 hours because metronidazole is recommended as first-line therapy for mild to moderate C. difficile infection, and the patient's WBC of 18,000 and fever suggest moderate rather than severe disease; also initiate contact precautions and use alcohol-based hand sanitizer. 3. Place the client in a negative-pressure airborne infection isolation room because C. difficile spores can be disseminated through the air; instruct visitors and staff to wear N95 respirators, and perform hand hygiene with alcohol-based rub after removing gloves; continue the oral vancomycin but also request an order for loperamide to manage the diarrhea. 4. Administer the vancomycin orally as ordered because oral or rectal vancomycin is required to reach the colonic lumen for C. difficile (IV does not reach the colon for this indication); place the client on contact (enteric) precautions in a private room, use soap and water for hand hygiene because alcohol does not kill spores, and stop unnecessary other antibiotics that perpetuate dysbiosis. **✔ Correct answer** **Correct answer: 4** ## Explanation Severe C. difficile infection (CDI) is treated with oral or rectal vancomycin 125 mg every 6 hours for 10 days, OR fidaxomicin 200 mg every 12 hours, per current IDSA/SHEA and ACG guidelines. Important pharmacokinetic point: oral vancomycin is poorly absorbed from the GI tract and remains in the colonic lumen, which is exactly where C. difficile lives. IV vancomycin reaches systemic tissues but does not enter the colonic lumen at therapeutic concentrations and is therefore not effective for CDI; conversely IV vanco is for systemic gram-positive infections like MRSA and is not useful for CDI. Important nursing actions for CDI: (1) administer oral vancomycin per order; (2) implement contact (enteric) precautions and a private room or cohort with another CDI patient; (3) hand hygiene with soap and water — alcohol-based hand rubs do not kill C. difficile spores; (4) review antibiotic therapy and stop or narrow agents that perpetuate dysbiosis (FQs, clindamycin, broad cephalosporins) when possible; (5) avoid antimotility agents such as loperamide in severe disease because they can worsen toxic megacolon; (6) monitor for fulminant CDI signs — hypotension, ileus, megacolon, requires surgical evaluation; (7) educate household and visitors. Switching to IV, mixing with milk, or discharging on severe CDI are unsafe. ## In-depth explanation Oral vancomycin is the only vancomycin route that treats CDI. Soap and water for hands; alcohol does not kill spores. 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Always follow current clinical guidelines and your institution’s protocols._