Question

The client has MRSA and receives vancomycin (Vancocin) intravenously (IV). The nurse assesses an upper body rash and decreased urine output. What is the nurse's prior action?

A. obtain a stat x-ray, and notify the physician
B. stop the infusion of vancomycin (Vancocin), and notify the physician
C. administer an antihistamine
D. obtain a sterile urine specimen, and notify the physician

Answer 1

If a client with MRSA receiving vancomycin intravenously (IV) presents with an upper body rash and decreased urine output, the nurse's prior action should be to stop the infusion of vancomycin (Vancocin) and notify the physician.

Step-by-step explanation:

If a client with MRSA receiving vancomycin intravenously (IV) presents with an upper body rash and decreased urine output, the nurse's prior action should be to stop the infusion of vancomycin (Vancocin) and notify the physician (Option B).

An upper body rash can be a sign of an allergic reaction to vancomycin, and decreased urine output might indicate kidney damage. Both of these symptoms require immediate attention and assessment by the physician.

In the meantime, the nurse should stop the infusion to prevent further administration of the medication and potential worsening of the symptoms.