護理師正在給予靜脈注射萬古黴素（Vancomycin）。哪些發現需要護理師立即通知醫師？（選所有適合的）
A nurse is administering IV Vancomycin. Which findings would require the nurse to notify the physician immediately? (Select all that apply.)
- AFlushing of the face and neck臉部潮紅
- BHypotension✓ 正解低血壓
- CWheezing and dyspnea✓ 正解喘鳴和呼吸困難
- DInfusion site redness輸注部位發紅
- EBack and chest pain✓ 正解背部和胸部疼痛
萬古黴素輸注常見副作用為紅人症候群（Red Man Syndrome），屬於輸注速率相關的類過敏反應，表現為面頸部潮紅。然而，若出現低血壓、呼吸困難、喘鳴或胸背痛，則表示反應已惡化為嚴重的全身性過敏反應（Anaphylaxis），此時必須立即停止輸注並啟動緊急處置。臨床上，護理師應區分單純的潮紅與危及生命的過敏反應，並依據 ABC 原則（呼吸、循環）採取行動。
A common side effect of vancomycin infusion is Red Man Syndrome, an infusion rate-related pseudoallergic reaction that manifests as flushing of the face and neck. However, the development of hypotension, dyspnea, wheezing, or chest or back pain indicates progression to a severe systemic allergic reaction (anaphylaxis); at that point, the infusion must be stopped immediately and emergency interventions initiated. Clinically, the nurse must distinguish simple flushing from a life-threatening allergic reaction and act in accordance with the ABCs (breathing, circulation).
美國臨床對於萬古黴素的給藥規範非常嚴格，通常要求輸注時間至少 60-90 分鐘，以預防紅人症候群。若發生過敏反應，美國護理師常需立即執行過敏反應 Protocol（如給予 epinephrine, diphenhydramine）。