NCLEX-PN® ExaminationPharmacological TherapiesMedium
A client is prescribed intravenous vancomycin. The LPN initiates the infusion and observes the client developing a sudden rash on the face and upper body, flushing, and mild hypotension. Which of the following is the most appropriate initial action by the LPN?
- AElevate the client's legs and administer oxygen.
- BAdminister a STAT dose of diphenhydramine.
- CIncrease the IV infusion rate to dilute the medication.
- DStop the vancomycin infusion immediately.
Show answer & explanationAnswer & explanation
Correct answer: D. Stop the vancomycin infusion immediately.
The client's symptoms (rash, flushing, hypotension) are classic signs of 'Red Man Syndrome,' a common reaction to rapid vancomycin infusion. The immediate priority is to stop the infusion to prevent further reaction and then notify the registered nurse and healthcare provider.
Why the other options are wrong
- A. These are supportive measures that may be taken after stopping the infusion and assessing the client, but stopping the causative agent is paramount.
- B. While diphenhydramine may be administered later, the immediate priority is to stop the causative agent. An LPN cannot administer a STAT medication without an order, which would come after stopping the infusion and notifying the RN/provider.
- C. Increasing the infusion rate would worsen the reaction by delivering more vancomycin quickly.
Red Man Syndrome
An adverse reaction to rapid intravenous infusion of vancomycin, characterized by flushing, rash, pruritus, and hypotension, primarily affecting the face, neck, and upper torso.
- Caused by rapid vancomycin infusion.
- Symptoms: flushing, rash, pruritus, hypotension.
- Not an allergic reaction, but a histamine release.
- Management: stop infusion, slow rate for future doses.
Memory trick: RED MAN: Recognize, Emergency, Discontinue, Management, Assess, Notify