A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

A. Herpes simplex virus 2: Herpes simplex virus infections are not typically reportable to the

Centers for Disease Control and Prevention (CDC). These infections are commonly managed at the local level.

B. Candida albicans: Candida albicans infections are not typically reportable to the CDC. Candida species are common pathogens and are usually managed at the local level.

C. Staphylococcus aureus: Staphylococcus aureus infections, including methicillin-resistant

Staphylococcus aureus (MRSA), are not typically reportable to the CDC unless part of a larger outbreak or public health concern.

D. Lyme disease: Lyme disease is a reportable infection that requires notification to public health authorities, including the Centers for Disease Control and Prevention (CDC). Lyme disease is a vector-borne illness transmitted through the bite of infected ticks.

A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.

B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.

C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.

D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.