A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the clien experiencing a vancomycin infusion reaction?

A) Instruct the ’lient that their central line dressing must be changed every 24 hr: While it's essential to maintain proper hygiene a’d care for a central line to prevent infection, changing the dressing every 24 hours may not be necessary. The frequency of dressing changes depends on institutional policies and the client's condition. Providing accurate informat’on about dressing changes based on specific guidelines is important for the client's safety and the prevention of central l’ne-related infections.

B) Instruct the client to weigh themselves daily and record their weight: This is the correct instruction. Monitoring daily weight allows for the assessment of fluid status and the effectiveness of TPN therapy. Weight gain or loss can indicate fluid retention or depletion, respectively, which may necessitate adjustments to the TPN prescription. Recording daily weights provides valuable data for healthcare providers to evaluate the client's response to TPN and make appropriate m’difications to the treatment plan.

C) Instruct the client that one container of TPN may infuse for up to 72 hr: The duration of TPN administration varies depending on factors such as the client's nutritional needs, medical condition, ’nd the stability of the TPN solution. While some TPN solutions may be stable for up to 24-48 hours, infusing for 72 hours could increase the risk of contamination and compromise the integrity of the solution, leading to adverse effects. Providing accurate information about the duration of TPN infusion based on the specific prescription ensures the client's safety and the efficacy of therapy.

D’ Instruct the client to speed up the rate of their TPN infusion if it falls behind schedule: Altering the rate of TPN infusion without healthcare provider guidance can lead to complications such as hyperglycemia, electrolyte imbalances, or fluid overload. TPN infusion rates are carefully prescribed based on the client's nutritional needs and metabolic status’ If the infusion falls behind schedule, it's essential for the client to contact th’ir healthcare provider for guidance on adjusting the infusion rate or managing any potential issues.

Answer: B. Dispose of the remaining medication while another nurse observes.

Rationale:

A. Return the remaining medication to the facility's pharmacy:
Returning unused medication to the pharmacy is a common practice; however, it typically applies to unopened or excess stock. In this case, the medication has been partially administered, and returning it is not appropriate. The facility may have specific protocols regarding handling partial doses of controlled substances.

B. Dispose of the remaining medication while another nurse observes:
This action is appropriate as it follows safety protocols for controlled substances. Having another nurse witness the disposal ensures accountability and transparency, which is crucial in preventing misuse or diversion of medication. The facility likely has procedures for the safe disposal of narcotics, making this the correct choice.

C. Store the remaining half of the pill in the automated medication dispensing system:
Storing partial doses in the automated dispensing system is not permitted. This could lead to confusion regarding dosing and may violate policies on medication management, especially for controlled substances.

D. Place the remaining half of the pill in the unit-dose package:
Repackaging leftover medication is inappropriate for controlled substances due to the risk of misadministration and tracking issues. This could also violate safety regulations, as it complicates accountability for medication use.