The nurse is caring for a client with staphylococcus epidermidis. The client is on a vancomycin IV. What nursing consideration should the nurse be aware of regarding this medication?

  1. The client should only order from the low-residue-diet menu.
  2. The nurse should assist the client to ambulate.
  3. The nurse will need to draw blood before administration to determine trough levels.
  4. The client should be monitored for cardiac arrhythmias.
Number 3 is correct.
Rationale: The nurse will need to draw blood to monitor peak and trough levels of vancomycin in order to reduce the chance of side effects caused by toxicity. A low-residue diet and assistance with ambulation are unrelated to the vancomycin administration. Cardiac arrhythmia can be caused by antibiotics, but is not a common reaction.