— 藥理與非經腸給藥 · MEDIUM · SATA —
病人正在接受靜脈輸注 Vancomycin。護理師應立即回報哪些評估發現？（選所有適合的）
A client is receiving vancomycin IV. Which assessment findings should the nurse report to the provider immediately? (Select all that apply.)
- AFlushing of the face, neck, and chest✓ 正解臉部、頸部和胸部潮紅
- BDecreased urine output✓ 正解尿量減少
- CElevated creatinine levels✓ 正解肌酸酐值升高
- DBlood pressure 110/70 mmHg血壓 110/70 mmHg
- EWheezing or difficulty breathing✓ 正解喘鳴或呼吸困難
— Explanation · 中文詳解 —
Vancomycin 具有腎毒性與耳毒性，且輸注過快常引起紅人症候群（Red man syndrome）。選項 A 為紅人症候群典型表現；B 與 C 代表腎功能損害；E 則暗示嚴重的過敏反應（過敏性休克）。這四項均為需停藥或採取醫療介入的警訊。
Vancomycin is nephrotoxic and ototoxic, and rapid infusion frequently causes Red Man Syndrome. Option A reflects the classic presentation of Red Man Syndrome; options B and C indicate renal impairment; option E suggests a severe allergic reaction (anaphylaxis). All four findings are warning signs that warrant discontinuation of the drug or medical intervention.
✦ 台美臨床差異
美台皆針對 Vancomycin 實行嚴格的藥物濃度監測（Trough level），流程差異不大。