護理師正給予萬古黴素（vancomycin）的靜脈輸注。病人出現紅色、搔癢的皮疹和臉部潮紅。護理師應預期下列哪些醫囑？（選所有適合的）
A nurse is administering an IV infusion of vancomycin. The client develops a red, itchy rash and flushing. The nurse should anticipate which of the following orders? (Select all that apply.)
- AAdminister diphenhydramine.✓ 正解給予苯海拉明
- BStop the infusion.✓ 正解停止輸注
- CIncrease the infusion rate.加快輸注速度
- DNotify the physician.✓ 正解通知醫師
- EAdminister a fluid bolus.給予靜脈輸液衝刺
本題測試對萬古黴素（vancomycin）輸注副作用的辨識與處置。病人的症狀（紅疹、搔癢、潮紅）為典型的「紅人症候群（Red Man Syndrome）」，這是由於藥物輸注過快導致組織胺（histamine）大量釋放所引發的非過敏性反應。臨床處理的首要原則是立即中斷刺激源（停止輸注），接著給予抗組織胺藥物緩解症狀。護理師必須通知醫師評估後續劑量調整或降低輸注速率的必要性。此流程符合 NCLEX 對於藥物安全與病人權益的優先順序。
This item tests recognition and management of vancomycin infusion-related adverse effects. The client's symptoms (rash, itching, and flushing) are typical of Red Man Syndrome, a non-allergic reaction caused by a rapid infusion rate that triggers massive histamine release. The first clinical priority is to immediately stop the offending stimulus (stop the infusion), then administer an antihistamine to relieve symptoms. The nurse must notify the physician so that subsequent dose adjustments or a reduction in infusion rate can be evaluated. This sequence aligns with NCLEX priorities for medication safety and patient advocacy.
在美國臨床實務中，對於紅人症候群，醫師常會開立醫囑將輸注時間延長至 2 小時以上（例如 1g 藥物至少輸注 60-120 分鐘），且護理師在給藥前若發現速率過快常會主動要求修正。台灣臨床有時會因輸液幫浦設定習慣不同，若未嚴格執行給藥時間規範，較易忽略此類反應的預防。