# A client receiving IV vancomycin develops flushing of the neck and upper torso during the infusion. Which nursing action is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397134&lang=en  
> language: en  
> subject: Medication Administration  
> category: PPT

## Question

A client receiving IV vancomycin develops flushing of the neck and upper torso during the infusion. Which nursing action is most appropriate?

## Option

1. Increase the infusion rate to finish the dose sooner.
2. Document the finding as an expected therapeutic response.
3. Prepare to administer a thrombolytic medication.
4. Stop or slow the infusion and notify the provider according to protocol. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Flushing during vancomycin infusion suggests an infusion-related reaction that is managed by stopping or slowing the infusion and following protocol. Increasing the rate can worsen symptoms. The finding is not a therapeutic effect and is unrelated to thrombolytic therapy.

## 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 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.

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