— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正在給予靜脈輸注萬古黴素（vancomycin）。病人隨後出現潮紅、低血壓與搔癢症狀。護理師應採取何種行動？
A nurse is administering a dose of intravenous vancomycin. The client develops flushing, hypotension, and pruritus. Which action should the nurse take?
- ANotify the rapid response team通知快速反應小組
- BIncrease the infusion rate加快輸注速率
- CAdminister an intramuscular antihistamine給予肌肉注射抗組織胺
- DStop the infusion immediately✓ 正解立即停止輸注
— Explanation · 中文詳解 —
上述症狀為萬古黴素輸注症候群（Red Man Syndrome），主要與藥物輸注速率過快導致組織胺大量釋放有關。第一優先動作為暫停輸注，待症狀緩解後，依照醫囑以更慢的速度重新滴注，而非直接進行藥物治療或加壓。
These symptoms are consistent with vancomycin infusion reaction (Red Man Syndrome), primarily related to too-rapid infusion causing massive histamine release. The first-priority action is to pause the infusion; once symptoms resolve, the infusion is restarted at a slower rate as ordered, rather than immediately administering medication or initiating pressure support.
✦ 台美臨床差異
台灣臨床常見將此症狀視為輸注過快，護理師多依經驗先行暫停並與藥師討論稀釋濃度與速率。