A nurse is collecting data from a client who is receiving vancomycin for a Clostridium difficile infection.
Which of the following findings is the priority for the nurse to report to the provider?

Choice A rationale:

Levalbuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Therefore, a decrease in wheezing is a therapeutic effect of the medication, making this the correct choice.

Choice B rationale:

While levalbuterol can cause an increase in respiratory rate as a side effect, it is not considered a therapeutic effect of the medication. The primary goal of levalbuterol is to improve breathing by relaxing the muscles of the airways, not to increase respiratory rate.

Choice C rationale:

Levalbuterol does not directly affect nausea. It is primarily used to treat conditions related to breathing such as asthma and chronic obstructive pulmonary disease.

Choice D rationale:

An increased heart rate is a potential side effect of levalbuterol, not a therapeutic effect.

Choice A rationale:

Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.

Choice B rationale:

The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.

Choice C rationale:

Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.

Choice D rationale:

Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.