護理師正為病人靜脈輸注萬古黴素（vancomycin）。護理師發現病人的臉部、頸部和胸部出現潮紅。護理師應先採取哪項行動？
A nurse is administering an intravenous (IV) infusion of vancomycin to a client. The nurse notes that the client’s face, neck, and chest have become flushed and red. Which action should the nurse take first?
- AAssess the client for swelling of the lips and difficulty breathing評估病人是否有嘴唇腫脹和呼吸困難
- BStop the infusion immediately and notify the doctor立即停止輸注並通知醫師
- CAdminister PRN diphenhydramine as ordered依醫囑給予處方用苯海拉明 (diphenhydramine)
- DSlow the rate of the infusion✓ 正解減慢輸注速率
此臨床表現被稱為『紅人症候群』（Red Man Syndrome），並非真正的過敏反應（Type I hypersensitivity），而是因為萬古黴素輸注速度太快，導致肥大細胞直接釋放組織胺所致。處置方式是將輸注速度調慢（通常建議每 500mg 至少輸注 60 分鐘以上），症狀通常會隨之緩解。除非病人出現過敏性休克（Anaphylaxis）的徵兆，如喉頭水腫或呼吸困難，否則不需要立即停藥。這題的核心在於區分紅人症候群與過敏反應。如果只是輕微潮紅，調慢速度即可（D）；若懷疑是過敏反應（A），則優先順序會改變。但題目中描述的是典型的速度相關反應，首選處置是調整流速。
This clinical presentation is known as 'Red Man Syndrome.' It is not a true allergic (type I hypersensitivity) reaction but rather histamine release from mast cells caused by overly rapid infusion of vancomycin. Management is to slow the infusion rate (a common recommendation is to infuse at least 60 minutes per 500 mg dose), and symptoms typically resolve. Unless the client shows signs of anaphylaxis such as laryngeal edema or respiratory distress, the medication does not need to be stopped immediately. The key is distinguishing Red Man Syndrome from a true allergic reaction. With mild flushing, slowing the rate is appropriate (D); if anaphylaxis is suspected (A), the priorities change. In this scenario the description is a classic rate-related reaction, and the first-line intervention is rate adjustment.
在美國，萬古黴素常在門診輸注中心由 RN 依據 Protocol 自行調整速度。台灣則多在住院環境使用，護理師若發現紅人症候群通常會先減速或暫停，再向醫師確認後續滴數。