Question

The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse: A. Call the doctor B. Stop the IV infusion of Vancomycin C. Administer Benadryl as ordered D. Take the vital signs

Short answer

Question: Arrange the actions a nurse must take when noticing redness on the neck and chest of a client being treated with intravenous Vancomycin for MRSA in the correct order. Answer: B. Stop the IV infusion of Vancomycin, D. Take the vital signs, A. Call the doctor, C. Administer Benadryl as ordered.

Step-by-step solution

Stop the IV infusion of Vancomycin

First and foremost, the nurse needs to stop the IV infusion of Vancomycin immediately. This is because the redness on the client's neck and chest could be a sign of an allergic reaction or other adverse effects caused by the medication. By stopping the infusion, the nurse prevents the situation from worsening due to continuous drug administration.

Take the vital signs

After stopping the IV infusion, the nurse must take the patient's vital signs, including blood pressure, heart rate, respiratory rate, and temperature. By doing this, the nurse can assess the seriousness of the situation and monitor any changes in the patient's condition, which is essential for the next course of action.

Call the doctor

Once the nurse has stopped the IV infusion and checked the patient's vital signs, they should call the doctor and report the situation. This is because the doctor needs to make a decision about the continuation of the treatment or any modifications to the treatment plan. By informing the doctor promptly, the nurse ensures that the patient receives the appropriate medical care as soon as possible.

Administer Benadryl as ordered

If the doctor orders the nurse to administer Benadryl (an antihistamine medication), the nurse should follow the order and give the medication to the patient. Administering Benadryl helps in reducing the symptoms of an allergic reaction and provides relief to the patient. In conclusion, the ordered sequence of actions to be taken by the nurse in this situation would be: B. Stop the IV infusion of Vancomycin, D. Take the vital signs, A. Call the doctor, and C. Administer Benadryl as ordered.

Key concepts

Patient Assessment

Patient assessment is a critical component in nursing procedures and involves gathering essential information about the patient's current health status. It usually begins with observing and asking about any symptoms the patient might be experiencing. In the scenario at hand, the nurse noted redness on the client's neck and chest, which can indicate an allergic reaction. Recognizing these physical symptoms is a key part of assessment.
Next, the nurse needs to engage in collecting vital signs, which include measurements such as blood pressure, heart rate, respiratory rate, and temperature. These are crucial metrics that help evaluate the severity of the patient's condition. Understanding these indicators allows healthcare providers to make informed decisions about the next steps in the patient's care plan. It's important to take these measurements immediately in situations suggesting an allergic response, to ensure prompt and appropriate medical interventions.

Medication Administration

Medication administration is a routine aspect of nursing practice but requires great precision and attention to detail. Nurses must administer medications safely and effectively to ensure they benefit the patient without causing adverse effects. In emergency situations, such as a suspected allergic reaction, it becomes even more critical.
During the medication administration process, nurses should always monitor the patient for any unusual reactions and be prepared to act quickly if adverse symptoms appear. The initial step to stopping medication, as in the case of an intravenous Vancomycin, signifies a crucial part of this process.

• Verify the right patient, medication, dose, route, and time.
• Monitor closely for any side effects or allergic reactions.
• Stop medication immediately if adverse reactions are observed.

Thorough documentation and clear communication with the medical team ensure that the patient's safety remains at the forefront.

Allergic Reactions

Allergic reactions are the body's response to a foreign substance, and in healthcare settings, they can be triggered by medications. Symptoms often include redness, itching, rashes, swelling, or in severe cases, difficulty breathing. Identifying these symptoms promptly is crucial to limit further complications.
In the exercise example, the nurse's ability to recognize redness as an allergic reaction and stop the Vancomycin infusion plays a critical role in patient safety. Further steps like notifying a doctor and potentially administering antihistamines, like Benadryl, which reduce allergic response, can alleviate symptoms and prevent escalation.
Understanding both the signs of an allergic reaction and appropriate responses ensures swift action, mitigating risks and safeguarding the patient’s health.

Intravenous Therapy

Intravenous (IV) therapy involves administering fluids, medications, or nutrients directly into a patient's bloodstream. This method allows medication to be absorbed quickly and efficiently, making it a vital part of medical treatment, particularly in hospitals.
While IV therapy provides significant benefits, it also requires careful monitoring. Nurses must ensure that the correct medication is administered and watch for any signs of complications, such as infiltration, inflammation, or allergic reactions. Stopping the IV is essential when a patient shows adverse reactions, as it halts further medication from compounding the issue.

• Ensure proper technique when inserting IV lines.
• Frequently assess the IV site and patient's response.
• Be prepared to stop the infusion at any sign of a negative reaction.

Through diligent vigilance and knowledge about IV therapy, nurses can perform one of the most direct and immediate forms of treatment effectively.