NCLEX Question of the Day – Saturday, February 28, 2026

Today’s question targets safe medication administration and recognizing infusion reactions. This skill matters because nurses are the last check before a drug reaches the patient. Early recognition and the right first action can prevent harm, escalate care appropriately, and keep therapy on track.

Clinical Scenario

A 72-year-old patient is on a medical-surgical unit with suspected urosepsis. Medical history includes hypertension and chronic kidney disease stage 3. The provider started IV vancomycin for broad-spectrum coverage. Ten minutes after the infusion begins, the patient reports feeling “hot and itchy.” You note flushing of the face, neck, and upper chest with scattered hives on the chest. Blood pressure is 110/64, heart rate 102, respirations 18, SpO2 97% on room air. Breath sounds are clear. There is no lip or tongue swelling, and the patient is speaking full sentences.

The Question

What is the nurse’s priority action?

Answer Choices

1. A. Stop the vancomycin infusion and maintain IV access with normal saline while assessing the airway
2. B. Administer epinephrine IM in the lateral thigh and call a rapid response
3. C. Apply oxygen at 6 L/min via simple face mask and place the patient in high Fowler position
4. D. Continue the infusion and document the reaction as expected with first-dose vancomycin

Correct Answer

A. Stop the vancomycin infusion and maintain IV access with normal saline while assessing the airway

Detailed Rationale

This presentation is most consistent with a vancomycin infusion reaction (VIR), previously called “red man syndrome.” It is a rate-related, non–IgE-mediated reaction. It happens when vancomycin is infused too quickly, causing histamine release. Typical signs include flushing of the face, neck, and upper torso, pruritus, and sometimes mild hypotension. There is usually no bronchospasm, no angioedema, and oxygenation remains stable.

The safest first action is to stop the offending stimulus: the vancomycin infusion. This limits ongoing histamine release and prevents progression. Maintaining IV access with normal saline keeps a route for medications (e.g., antihistamines) and fluids if needed. While doing this, reassess airway, breathing, and circulation. Verify that there is no wheezing, stridor, or swelling that would suggest anaphylaxis.

After stabilizing, notify the provider. Expect orders to premedicate with an H1 blocker (e.g., diphenhydramine) and to restart vancomycin at a slower rate (often over ≥ 90–120 minutes), or adjust the dose and rate per pharmacy protocol. Also verify the correct concentration and tubing. Document the reaction, rate, and patient response.

Why this is priority: It directly removes the cause, preserves access for treatment, and addresses potential airway issues early. It is targeted, fast, and prevents escalation.

Why the Other Options Are Wrong

• B. Administer epinephrine IM and call a rapid response — This is the right move for anaphylaxis (airway compromise, wheeze/bronchospasm, severe hypotension, rapidly worsening symptoms). The patient here has stable vitals, clear lungs, no angioedema, and normal oxygenation. Jumping to epinephrine adds risk (tachyarrhythmias, hypertension) and does not match the current assessment.
• C. Apply oxygen at 6 L/min via simple face mask and place high Fowler — Oxygen is not needed when SpO2 is 97% on room air and there are no respiratory symptoms. Positioning may improve comfort but does not remove the cause. This misses the primary intervention: stop the infusion.
• D. Continue the infusion and document as expected — Continuing a likely rate-related reaction can worsen symptoms and lead to hypotension. A flushing and pruritic reaction is not “expected” to the point of ignoring; it signals the need to stop, reassess, treat, and resume at a slower rate under guidance.

Key Takeaways

• Vancomycin infusion reaction is rate-related. Flushing, pruritus, and upper torso erythema are classic. Airway is usually intact.
• First action: stop the infusion, keep IV access with normal saline, and reassess ABCs.
• Differentiate VIR from anaphylaxis. Anaphylaxis features airway edema, bronchospasm, hypoxia, and/or severe hypotension and needs epinephrine.
• Restart vancomycin only with provider guidance, often after antihistamine premedication and at a slower rate (e.g., over ≥ 90–120 minutes).
• Document rate, signs, timing, interventions, and patient response. Verify concentration and infusion setup before resuming.

• On-shift mini-checklist:
  • At start: confirm drug, dose, concentration, and ordered rate; use appropriate IV access.
  • First 15 minutes: stay close; check vitals and ask about itching, heat, or tightness.
  • If reaction: stop infusion, maintain IV with NS, assess ABCs, notify provider, anticipate antihistamine/order to slow rate.
  • After stabilization: educate patient about reporting symptoms early in future doses.

Quick Practice Extension

• You begin piperacillin-tazobactam and the patient develops wheezing, lip swelling, and a drop in BP to 78/46. What are your immediate first three actions?
• A patient with a prior vancomycin infusion reaction needs the next dose. What premedication and infusion adjustments would you clarify with the provider before starting?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com