護理師正給予萬古黴素（vancomycin）的靜脈輸注。在輸注前及輸注期間，哪項護理評估最重要？
A nurse is administering an IV infusion of vancomycin. Which nursing assessment is most critical to perform before and during the infusion?
- AClient's blood pressure and pulse rate✓ 正解病人的血壓和脈搏
- BClient's level of consciousness病人的意識程度
- CClient's respiratory rate and depth病人的呼吸速率和深度
- DClient's urine output病人的尿量
萬古黴素（vancomycin）輸注過程中，最常見的急性反應是「紅人症候群」（Red Man Syndrome），這是由於輸注速度過快導致組織胺（histamine）大量釋放所引起的類過敏反應。其臨床表現包括臉部、頸部及軀幹上部的潮紅、搔癢，嚴重時伴隨低血壓及心跳過速。因此，在輸注前及過程中密切監測病人的血壓與脈搏是評估血液動力學穩定的關鍵。若出現低血壓，必須立即停止或減慢輸注速率。這類評估體現了藥物治療中的安全優先原則（Safety），確保病人不會因輸注過快而陷入休克風險。
During vancomycin infusion, the most common acute reaction is Red Man Syndrome, an anaphylactoid reaction caused by massive histamine release when the infusion rate is too fast. Its clinical manifestations include flushing and pruritus of the face, neck, and upper trunk, accompanied in severe cases by hypotension and tachycardia. Therefore, closely monitoring the patient's blood pressure and pulse before and during the infusion is key to assessing hemodynamic stability. If hypotension occurs, the infusion must be stopped or slowed immediately. This type of assessment embodies the safety-first principle of pharmacotherapy, ensuring that the patient does not enter shock due to overly rapid infusion.
在美國臨床，萬古黴素輸注常會規範至少 60 分鐘以上，且護理師會嚴格執行輸注前後的生命徵象監測；台灣臨床亦遵循此原則，但在忙碌時，護理師需特別注意藥袋或醫囑上標註的輸注時間，避免為了趕點滴而擅自加速。