Care Manager Certification Practice Exam

After administering IV vancomycin, which finding should a nurse report to the provider as a priority?

1. Localized redness at the catheter insertion site.

2. Client report of a headache.

3. Client report of tinnitus.

4. Audible inspiratory stridor.

The correct answer is: Audible inspiratory stridor.

When considering the administration of IV vancomycin, one of the key concerns is the potential for an allergic reaction or a serious adverse event. Audible inspiratory stridor is indicative of airway obstruction or a severe allergic reaction, potentially leading to respiratory distress. It suggests that the patient may be experiencing anaphylaxis or significant allergic reaction, which requires immediate medical intervention. Stridor is a high-pitched wheezing sound generated from turbulent airflow in the upper airway and is a medical emergency. This symptom indicates a life-threatening situation that could lead to respiratory failure if not promptly addressed. As such, it takes precedence over other findings because it directly relates to the patient’s airway and ability to breathe. Localized redness at the catheter insertion site may suggest mild irritation or phlebitis, which, while important, does not pose an immediate threat to the patient's life. Client reports of a headache and tinnitus are also significant but are more common and less acutely dangerous compared to the potential implications of stridor. Thus, the presence of audible inspiratory stridor stands out as a critical finding that requires priority reporting to the healthcare provider for urgent evaluation and intervention.