護理師正在照顧接受萬古黴素（Vancomycin）輸注的病人，下列哪些評估發現需要立即處理？（選所有適合的）
A nurse is caring for a client receiving Vancomycin infusion. Which assessment finding requires immediate intervention? (Select all that apply.)
- ABlood pressure 90/60 mmHg✓ 正解血壓 90/60 mmHg
- BFlushing of the face and neck臉部與頸部潮紅
- CUrine output 10 mL in one hour✓ 正解一小時內尿量 10 mL
- DItching on the upper torso上半身搔癢
- EWheezing and shortness of breath✓ 正解喘鳴與呼吸困難
Vancomycin 的常見副作用如紅人症候群（Flushing/Itching）通常與輸注速度過快有關，雖需調整速度，但非危及生命的過敏反應。相反地，低血壓（Shock）、寡尿（腎毒性指標）以及喘鳴（過敏性休克）皆為危及生命的急性併發症，必須立即停止輸注並啟動緊急處置流程。
Common adverse effects of vancomycin such as Red Man Syndrome (flushing/itching) are typically related to rapid infusion rate; the rate must be adjusted but the reaction is not life-threatening. In contrast, hypotension (shock), oliguria (an indicator of nephrotoxicity), and wheezing (anaphylactic shock) are all life-threatening acute complications that require immediately stopping the infusion and activating an emergency response.
台灣與美國臨床對於 Vancomycin 監測皆極為重視，特別是針對過敏反應的鑑別診斷。