# Ten minutes after a vancomycin infusion begins, a client develops flushing, itching, and erythema of the neck and upper chest. What should the nurse do first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396579&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

Ten minutes after a vancomycin infusion begins, a client develops flushing, itching, and erythema of the neck and upper chest. What should the nurse do first?

## Option

1. Stop the infusion and assess the client's airway and vital signs. **✔ Correct answer**
2. Increase the infusion rate so the dose finishes sooner.
3. Document the finding as an expected therapeutic effect.
4. Administer the next scheduled dose without notifying anyone.

**Correct answer: 1**

## Explanation

Flushing and itching shortly after vancomycin starts suggest an infusion reaction. The nurse should stop the infusion, assess the client, and follow facility protocol and provider orders. Increasing the rate or ignoring the reaction can worsen symptoms.

## In-depth explanation

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 scenario

Clinical Practice Guide
For Vancomycin infusion reaction, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Vancomycin** — An antibiotic used for serious gram-positive infections.
- **Infusion Reaction** — A reaction related to medication administration rate or exposure.
- **Erythema** — Redness of the skin caused by increased blood flow or irritation.

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