A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the clien experiencing a vancomycin infusion reaction?

A) A client vomits after receiving an oral medication: While vomiting after medication administration should be documented in the client's medical record as it could indicate a ’otential adverse reaction or medication intolerance, it does not necessarily require an incident report unless there are unusual circumstances surrounding the event.

B) A client receives their meal tray 20 minutes before time: This situation does not require an incident report. It may be considered a minor deviation from the usual mealtime schedule, and no harm or adverse outcome is implied.

C) A client receives their insulin before scheduled time: This is the correct answer. Administering insulin before the scheduled time can pose significant risks to the client, potentially leading to hypoglycemia or other adverse effects. Such deviations from the prescribed administration time should be documented in an incident report to ensure appropriate investigation and prevention of recurrence.

D) A client experiences a seizure: While a client experiencing a seizure is a critical event that requires immediate nursing intervention and documentation, it does not typically warrant an incident report unless it occurs in unusual circumstances or if there are concerns about the client's safety or well-being during the seizur’.

A) Ex edicationr bubble from the syringe prior to administering the medication: Expelling air bubbles is necessary when administering medications via intravenous injection to prevent air embolisms. However, with subcutaneous injections like enoxaparin, the presence of small air bubbles is not usually a concern, and expelling them is not necessary.

B) Administer the medication into the anterolateral or posterolateral abdominal area: This is the correct action for administering enoxaparin. Enoxaparin is typically administered subcutaneously into the anterolateral or posterolateral abdominal wall. This site is preferred due to its high vascularity and good absorption of the medication.

C) Hold the skin taut at the injection site while administering the medication: While holding the skin taut can help reduce discomfort during the injection, it is not always necessary. The choice to hold the skin taut depends on the client's body habitus and the nurse's preferenc’. It is not a specific requi’ement for administering enoxaparin.

D) Massage the injection site after administering the medication: Massaging the injection site after administering enoxaparin is not recommended. It can increase bruising or bleeding at the injection site. Instead, after administering the medication, the nurse should apply gentle pressure with a dry cotton ball or gauze pad to help minimize bleeding.