護理師正在為病人進行靜脈注射萬古黴素（Vancomycin），發現病人面頸部潮紅且主訴發癢。護理師首要行動為何？
A nurse is administering intravenous vancomycin to a client. The nurse notes the client’s face and neck are flushing and the client reports feeling itchy. What is the nurse's priority action?
- AAdminister an antihistamine as ordered依醫囑給予抗組織胺。
- BStop the infusion immediately立即停止輸注。
- CSlow the rate of infusion✓ 正解減慢輸注速度。
- DNotify the healthcare provider通知醫療提供者。
此臨床情境描述的是典型的『紅人症候群（Red Man Syndrome）』，這並非真正過敏反應，而是萬古黴素輸注速度過快導致組織胺釋放的副反應。處理流程的第一步是減慢輸注速率，通常將速率降低後症狀會迅速緩解。若減慢速度後症狀消失，後續可繼續給藥；若症狀持續或嚴重則需停止。立即停止（B）並非必要，除非發生全身性過敏反應（休克、呼吸困難）。使用抗組織胺（A）是症狀治療，在處理好輸注速度前不是首要。通知醫師（D）是必要的處置，但護理師應先採取調整速率的獨立護理措施來緩解病人的不適，而非第一時間去通報。
This clinical scenario describes the classic 'Red Man Syndrome,' which is not a true allergic reaction but rather a histamine-release adverse effect caused by infusing vancomycin too rapidly. The first step in management is to slow the infusion rate; typically, symptoms quickly subside once the rate is reduced. If symptoms resolve after slowing the rate, administration can continue; if symptoms persist or are severe, the infusion should be stopped. Stopping the infusion immediately (B) is not necessary unless a systemic allergic reaction (shock, dyspnea) occurs. Administering an antihistamine (A) is symptomatic treatment and is not the first action before adjusting the infusion rate. Notifying the physician (D) is necessary but the nurse should first carry out the independent nursing intervention of adjusting the rate to relieve the client's discomfort, rather than reporting first.
美國護理師依據醫院協定（Protocol）可直接依臨床症狀調整輸注速率；台灣醫院通常要求若出現不良反應需先停止給藥並通知醫師評估後，才能重新調整速度繼續輸注。