病人正在進行靜脈輸注萬古黴素(vancomycin),護理師發現出現潮紅、低血壓與搔癢。下列何者為優先行動?
A client is prescribed intravenous vancomycin. The nurse notes the client develops flushing, hypotension, and pruritus during the infusion. Which action is the priority?
- ANotify the provider for an epinephrine order通知醫師開立腎上腺素醫囑
- BStop the medication infusion✓ 正解停止藥物輸注
- CSlow down the infusion rate減慢輸注速率
- DAdminister an antihistamine immediately立即給予抗組織胺
萬古黴素(Vancomycin)輸注過快會導致組織胺(histamine)大量釋放,引發紅人症候群(Red Man Syndrome),表現為潮紅、低血壓、搔癢或胸部不適。作為護理師,安全優先(Safety First),當出現輸注相關不良反應時,第一步驟應立即停止輸注以終止過敏原進入,隨後評估生命徵象並通知醫師,切勿直接減速或貿然給藥。
Rapid infusion of vancomycin can trigger massive histamine release and cause Red Man Syndrome, manifested as flushing, hypotension, pruritus, or chest discomfort. As a nurse, safety comes first: when an infusion-related adverse reaction occurs, the first step is to immediately stop the infusion to halt further entry of the allergen, then assess vital signs and notify the provider; do not simply slow the rate or hastily administer additional medication.