護理師照顧靜脈滴注萬古黴素 (Vancomycin) 的病人，病人出現臉部潮紅、低血壓及頸部、軀幹上部紅疹。護理師應優先採取何種措施？
A nurse is caring for a client who is receiving intravenous vancomycin. The nurse notes the client develops flushing, hypotension, and a rash on the neck and upper torso. What is the nurse's priority action?
- ADiscontinue the infusion and notify the provider停止靜脈滴注並通知醫師
- BAdminister an antihistamine immediately立即給予抗組織胺
- CSlow the infusion rate✓ 正解減慢靜脈滴注速度
- DIncrease the IV fluid flow rate增加靜脈輸液流速
此為典型的紅人症候群 (Red Man Syndrome)，是因為萬古黴素輸注速度過快導致組織胺大量釋放。首要處理方式是減慢或暫停輸注，待症狀緩解後再以更慢的速度輸注。並非過敏，故優先考慮調整速度而非給予抗組織胺。
This presentation is typical of Red Man Syndrome, caused by overly rapid infusion of vancomycin leading to massive histamine release. The primary intervention is to slow or pause the infusion; after symptoms resolve, the infusion can be restarted at a slower rate. Because this is not a true allergic reaction, adjusting the rate is preferred over administering an antihistamine as the first response.
兩地處理原則一致。美國護理師常有給藥指引可自行調慢速度，台灣臨床偶需先確認醫師意願，但多依教學原則先調慢。