— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人靜脈注射萬古黴素（Vancomycin），下列何種現象需要護理師立即處置？
A client is prescribed intravenous vancomycin for a severe infection. Which finding requires immediate intervention by the nurse?
- AThe client reports a mild metallic taste in the mouth病人主訴口中出現輕微的金屬味
- BThe client's face, neck, and upper chest appear flushed✓ 正解病人的臉部、頸部和上胸部出現潮紅
- CThe client requests an extra blanket due to chills病人因畏寒要求多加一條毯子
- DThe client's urine output is 50 mL in the last hour病人最後一小時的尿量為 50 mL
— Explanation · 中文詳解 —
Vancomycin 若滴注速度過快，會導致紅人症（Red Man Syndrome），出現臉部、頸部及上半身潮紅，伴隨搔癢或低血壓。護理師應立即停止或減慢輸注速度，並回報醫師。金屬味是常見副作用，尿量正常，畏寒則需進一步評估，潮紅才是需要即刻干預的徵象。
When vancomycin is infused too rapidly, it can produce red man syndrome, with flushing of the face, neck, and upper chest accompanied by itching or hypotension. The nurse should immediately stop or slow the infusion and notify the physician. A metallic taste is a common side effect; normal urine output and chills require further assessment, but it is the flushing that demands immediate intervention.
✦ 台美臨床差異
台美臨床對於 Vancomycin 輸注速度均嚴格監測，常要求至少一小時滴完。