Pharmacological and Parenteral Therapies
Flushing during a vancomycin infusion: first action
Question
Twenty minutes into an IV vancomycin infusion, a client develops flushing and itching across the face, neck and upper chest. Blood pressure is stable and breathing is unlabored. What is the nurse's first action?
Show the answer and rationale
Correct answer: D
A. Incorrect. These reactions come from giving the drug too fast. The label says to infuse vancomycin over no less than 60 minutes to avoid them, so a faster rate makes things worse.
B. Incorrect. Flushing during the infusion is a reaction to act on, not a finding to chart while the drug keeps running.
C. Incorrect. A compress treats the itch, not the cause. With the infusion still running, the reaction can go on and get worse.
D. Correct. The label describes flushing of the upper body as a reaction to rapid infusion and says stopping the infusion usually ends these reactions promptly. The prescriber then decides how to continue.
Source: FDA-approved label: Vancomycin hydrochloride for injection, on DailyMed
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