A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider?
Explanation & Rationale
A. Client report of a headache: While a headache can be a side effect of vancomycin, it is not the most urgent or life-threatening issue to report immediately unless it is accompanied by other symptoms of a more serious reaction (such as dizziness or confusion). B. Audible inspiratory stridor: Inspiratory stridor indicates airway obstruction, which can be a sign of an anaphylactic or severe allergic reaction. This is the most urgent and serious finding that requires immediate attention. Stridor indicates a potential life-threatening condition that needs immediate intervention. C. Client report of tinnitus: Tinnitus can be a sign of ototoxicity, a known adverse effect of vancomycin, particularly when given in high doses or rapidly. While important, it is not as urgent as airway obstruction (stridor), though it still warrants monitoring. D. Localized redness at the catheter insertion site: Localized redness at the catheter site may indicate mild irritation or phlebitis, which can occur with IV vancomycin. While this should be monitored, it is not as urgent or critical as signs of airway obstruction (stridor).