A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?

A) This is correct because using two client identifiers, such as name and date of birth, is a standard safety measure to ensure that the right medication is given to the right client.

B) This is correct because checking the expiration date of the medication before administering it is another safety measure to prevent giving expired or ineffective medications to clients.

C) This is correct because comparing the medication label with the prescription three times (before, during, and after preparing the medication) is a recommended practice to prevent errors such as wrong dose, wrong route, or wrong time.

D) This is incorrect because administering the medication as soon as possible after receiving it from the pharmacy may increase the risk of errors due to haste or distraction. The nurse should follow the prescribed schedule and administer the medication within a reasonable time frame.

E) This is incorrect because documenting the medication administration after completing other tasks may lead to forgetting or omitting important information. The nurse should document the medication administration as soon as possible after giving it to the client.

A) This is correct because blood in the urine (hematuria) is a sign of bleeding that should be reported to the provider. Warfarin is an anticoagulant that can increase the risk of bleeding from any site in the body.

B) This is correct because a headache that lasts for more than an hour is a sign of bleeding that should be reported to the provider. Warfarin can increase the risk of bleeding in the brain (intracranial hemorrhage), which can manifest as a severe or persistent headache, confusion, or neurological deficits.

C) This is correct because black, tarry stools (melena) are a sign of bleeding that should be reported to the provider. Warfarin can increase the risk of bleeding in the gastrointestinal tract (GI bleed), which can manifest as dark or bloody stools, abdominal pain, or vomiting blood.

D) This is correct because a sore throat and a fever are signs of bleeding that should be reported to the provider. Warfarin can increase the risk of bleeding in the mucous membranes (mucosal bleeding), which can manifest as sore throat, mouth ulcers, nosebleeds, or gum bleeding. A fever may indicate an infection that can worsen the bleeding tendency.

E) This is incorrect because bruising on the arms and legs (ecchymosis) is not a sign of bleeding that should be reported to the provider. Warfarin can cause minor bruising due to subcutaneous bleeding, which is usually harmless and does not require treatment. However, if the bruising is extensive, painful, or accompanied by other signs of bleeding, then it should be reported to the provider.