病人因嚴重葡萄球菌感染接受靜脈注射萬古黴素（Vancomycin）。護理師應優先監測下列何者以預防嚴重不良反應？
A client is prescribed intravenous Vancomycin for a severe Staphylococcal infection. Which finding should the nurse prioritize to prevent a severe adverse reaction?
- AReview the client's most recent creatinine clearance檢視病人最近的肌酸酐清除率
- BAssess for signs of local phlebitis at the site評估注射部位是否有局部靜脈炎的徵象
- CMonitor the infusion rate to prevent Red Man Syndrome✓ 正解監測輸注速率以預防紅人症候群
- DEnsure the client has a patent peripheral IV line確保病人周邊靜脈留置針通暢
萬古黴素若輸注過快會誘發組織胺大量釋放，導致「紅人症候群（Red Man Syndrome）」，表現為低血壓、潮紅及搔癢。此為藥物給予時最需立即注意的護理作為，建議給藥時間需大於 60 分鐘。A 選項雖涉及腎毒性監測，但對即刻藥物安全而言，輸注速率控制更為迫切。
If vancomycin is infused too rapidly, large amounts of histamine are released, producing "Red Man Syndrome," which presents with hypotension, flushing, and pruritus. Preventing this is the most immediate nursing priority during administration; the infusion should run over more than 60 minutes. Option A involves monitoring for nephrotoxicity, but with respect to immediate medication safety, controlling the infusion rate is more urgent.
台灣醫院通常規定萬古黴素給藥需分兩袋或嚴格控制時間；美國護理師對給藥速率的自主判定權責較高。