During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.

Choice A rationale:

While it’s important for the client’s family to be aware of the disease and take precautions, they do not necessarily need to take medications to prevent infection. Tuberculosis (TB) is a contagious disease, but it typically requires close and prolonged contact to spread. Family members should be tested for TB, and if they test positive, then treatment would be necessary.

Choice B rationale:

This is the correct answer. A typical course of treatment for TB involves 6 to 9 months of consistent medication use. This is because TB bacteria die very slowly, and medications need to be taken for several months to ensure that all the bacteria are killed. If treatment is stopped too soon, some bacteria may survive and become resistant to the drugs.

Choice C rationale:

It’s not accurate to say that medications will need to be taken for the rest of the client’s life. While TB treatment is lengthy, it does not continue indefinitely. Once the full course of treatment is completed and the disease is cured, further medication is not typically necessary.

Choice D rationale:

The Mantoux test, also known as the tuberculin skin test, is used to determine whether a person has TB infection. However, the test can remain positive for a long time, even after successful treatment. Therefore, medications should not be taken until the Mantoux test is negative. Instead, the duration of treatment is determined by the healthcare provider based on various factors, including the patient’s response to the medication.