病人正在靜脈滴注萬古黴素（Vancomycin），護理師發現病人臉部與頸部潮紅，血壓降至 85/50 mmHg。護理師應優先採取的行動為何？
A client is receiving an IV infusion of vancomycin. The nurse notices the client's face and neck are flushed, and blood pressure has dropped to 85/50 mmHg. What is the priority nursing action?
- AAdminister a fluid bolus給予輸液衝刺
- BAdminister an antihistamine給予抗組織胺
- CSlow the infusion rate減慢輸注速率
- DStop the infusion immediately✓ 正解立即停止輸注
此狀況為萬古黴素引起的輸注反應（紅人症候群），若出現低血壓等血流動力學不穩，應立即停止輸注。單純潮紅可減速，但血壓驟降代表過敏性反應，需先停止藥物。B 與 A 為後續處置，先移除誘發因素才能阻斷過敏惡化。
This presentation reflects a vancomycin infusion reaction (red man syndrome). When hemodynamic instability such as hypotension develops, the infusion must be stopped immediately. Isolated flushing can be managed by slowing the rate, but a sudden drop in blood pressure indicates an anaphylactoid reaction, and the medication must be discontinued first. Options B and A are subsequent interventions; the offending agent must be removed before the reaction can be controlled.
美台臨床對於輸注反應的處置均強調先停藥，美國護理師依醫囑給予 Epinephrine 的權限較高。