一位病人正接受靜脈注射萬古黴素（vancomycin）。護理師觀察到病人的臉部、頸部和上胸部出現潮紅。護理師接下來應採取什麼措施？
A client is prescribed intravenous vancomycin. The nurse observes flushing of the face, neck, and upper chest during administration. What is the nurse's next step?
- ASlow the rate of infusion✓ 正解減慢輸注速度
- BStop the infusion immediately立即停止輸注
- CAdminister an antihistamine as ordered依醫囑給予抗組織胺
- DIncrease the IV fluid rate增加靜脈輸液速度
此症狀為典型的『紅人症候群』（Red Man Syndrome），由萬古黴素輸注速度過快引起的組胺釋放，並非真正的過敏反應（anaphylaxis）。處理的首要原則是暫時降低輸注速度，觀察症狀是否減緩。若症狀持續或惡化，才需要停止輸注並評估過敏的可能性。選項 B 是過度反應，因為這通常不是致命的過敏；選項 C 常見於治療症狀，但在調整輸注速度之前並非首選，因為單靠抗組織胺無法解決根本的輸注速度問題；選項 D 對於處理藥物引起的組胺釋放無實質臨床助益。掌握此類藥物動力學副作用與過敏反應的區別，是 NCLEX 護理師必備的藥物管理能力。
This symptom is the classic 'Red Man Syndrome,' caused by histamine release due to rapid vancomycin infusion, and is not a true anaphylactic reaction. The first priority of management is to temporarily slow the infusion rate and observe whether symptoms abate. If symptoms persist or worsen, the infusion should be stopped and the possibility of true allergy assessed. Option B is an overreaction because this is usually not a life-threatening allergy; option C, treating symptoms with antihistamines, is commonly used but is not the first choice before adjusting the infusion rate, because antihistamines alone do not address the underlying issue of infusion speed; and option D provides no clinical benefit for histamine release induced by the medication. Distinguishing this pharmacokinetic side effect from a true allergic reaction is an essential medication management competency for NCLEX nurses.
美國護理師受過更強化的『輸注速度調整』訓練，對於藥物副作用的判斷更傾向臨床評估而非單純依賴醫囑；台灣醫院多有標準規範（如輸注過快導致副作用需停藥並聯絡藥師與醫師），對護理師自主調控速率的靈活度限制較多。