The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min
The nurse notes red blotches on the patient's face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?
a. Request an order for IV epinephrine to treat anaphylactic shock.
b. Slow the infusion to 10 mg/min and observe the patient closely.
c. Stop the infusion and obtain an order for a BUN and serum creatinine.
d. Suspect Stevens-Johnson syndrome and notify the provider immediately.
ANS: B
When vancomycin is infused too rapidly, "red man" syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.
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