護理師準備靜脈輸注 Vancomycin 1g。病人基礎肌酸酐為 0.8 mg/dL。給藥前最合適的護理措施為何？
A nurse is preparing to administer Vancomycin 1g intravenously. The nurse notes the client has a baseline creatinine of 0.8 mg/dL. Which nursing action is most appropriate prior to hanging the medication?
- AEnsure the infusion rate is over at least 60 minutes✓ 正解確保輸注時間至少為 60 分鐘
- BAdminister a fluid bolus to protect the kidneys給予液體推注以保護腎臟
- CRequest a baseline hearing test要求進行基線聽力測試
- DDraw a trough level if the previous dose was 30 minutes ago若上一劑給藥後已過 30 分鐘，則抽取波谷濃度
Vancomycin 若滴注過快易引發「紅人症候群（Red Man Syndrome）」，常見特徵為上半身潮紅、低血壓、搔癢。標準指引要求 1g 劑量至少需輸注 60 分鐘。D 選項錯誤，波谷濃度（trough）應於下一劑給藥前 30 分鐘抽血。C 為預防措施但非給藥原則。D 非給藥前必要步驟。
Rapid infusion of Vancomycin can precipitate Red Man Syndrome, characterized by flushing of the upper body, hypotension, and pruritus. Standard guidelines require that a 1g dose be infused over at least 60 minutes. Option D is incorrect because trough levels should be drawn 30 minutes before the next dose, not after a previous dose. Option B may be a preventive measure but is not a routine administration principle. Option C is not a required step prior to administration.
美台臨床皆嚴格要求慢速輸注以防過敏反應，台灣護理師常需更頻繁監測血壓變化。