PN Adult Medical Surgical Practice Exam

When caring for a client receiving IV vancomycin, which side effect should the nurse monitor for?

1. Hypotension.

2. Red man syndrome.

3. Nephrotoxicity.

4. Anaphylaxis.

The correct answer is: Red man syndrome.

When caring for a client receiving IV vancomycin, monitoring for red man syndrome is particularly important. This adverse reaction is characterized by flushing, rash, pruritus, and hypotension, which usually occurs when the infusion of vancomycin is too rapid. It is not an allergic reaction but rather a histamine release response. To minimize the risk of red man syndrome, vancomycin should be administered slowly, typically over at least 60 minutes for a standard dose. While hypotension, nephrotoxicity, and anaphylaxis can also occur with vancomycin use, red man syndrome is a more immediate and commonly recognized side effect directly related to the infusion process. Therefore, vigilant monitoring for signs of red man syndrome is crucial for promoting the safe administration of this medication.