護理師正給予靜脈萬古黴素（vancomycin）。下列哪項發現需要停止輸注並通知醫師？（選所有適合的）
A nurse is administering IV vancomycin. Which finding necessitates stopping the infusion and notifying the physician? (Select all that apply.)
- AClient reports mild itching at the IV site.個案報告靜脈注射部位有輕微搔癢
- BClient develops a diffuse red rash and reports flushing.✓ 正解個案出現瀰漫性紅疹並報告潮紅
- CClient's blood pressure drops by 30 mmHg.✓ 正解個案血壓下降 30 mmHg
- DClient's urine output is 20 mL/hr.✓ 正解個案尿量為 20 mL/hr
- EClient reports mild nausea.個案報告輕微噁心
萬古黴素（Vancomycin）輸注時，護理師必須監控其潛在嚴重不良反應。紅人症候群（Red Man Syndrome）是因輸注過快導致組織胺釋放，表現為皮疹與潮紅；嚴重低血壓則顯示循環系統失代償；尿量減少（<30 mL/hr）是腎毒性（Nephrotoxicity）的早期徵兆。對於這些反應，首要行動是停止輸注（Safety/Priority），避免毒性進一步蓄積，隨後立即聯繫醫療團隊調整治療計畫。
When infusing vancomycin, the nurse must monitor for serious potential adverse reactions. Red Man Syndrome is caused by histamine release from too-rapid infusion and presents with rash and flushing; severe hypotension indicates circulatory decompensation; and decreased urine output (<30 mL/hr) is an early sign of nephrotoxicity. For these reactions, the first action is to stop the infusion (safety/priority) to prevent further accumulation of toxicity, and to immediately contact the medical team to adjust the treatment plan.
在美國臨床，萬古黴素給藥前常需進行血中濃度監測（Trough level），且藥局通常會嚴格執行輸注速度限制（至少60-90分鐘），以預防紅人症候群。