During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.

Choice A rationale:

Zidovudine, also known as AZT, is a medication used for the treatment of human immunodeficiency virus (HIV) infection. One of the major dose-limiting toxic effects of Zidovudine is hematologic toxicity, which manifests clinically as anemia, neutropenia, and sometimes as platelet deficits with onset after several weeks of treatment. This hematologic toxicity is essentially a form of bone marrow suppression. Therefore, bone marrow suppression is the dose-limiting adverse effect of zidovudine therapy.

Choice B rationale:

Retinitis is not a known dose-limiting adverse effect of zidovudine. While zidovudine has a range of side effects, retinitis is not commonly associated with its use.

Choice C rationale:

Renal toxicity is not a known dose-limiting adverse effect of zidovudine. While zidovudine can have various side effects, renal toxicity is not typically one of them.

Choice D rationale:

Hepatotoxicity is not the dose-limiting adverse effect of zidovudine. While severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of zidovudine, it is not considered the dose-limiting adverse effect. The dose-limiting adverse effect is more specifically related to hematologic toxicity, which includes bone marrow suppression.