— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人獲開立靜脈注射萬古黴素。輸注期間出現何種徵象，護理師需立即停止給藥？
A client is prescribed intravenous vancomycin. Which finding during infusion requires the nurse to immediately stop the medication?
- AThe client experiences a decrease in blood pressure to 90/60 mmHg✓ 正解病人血壓降至 90/60 mmHg
- BThe client develops flushing of the face, neck, and upper torso病人出現臉部、頸部和上半身潮紅
- CThe client reports itching without visible rash病人報告搔癢但無可見皮疹
- DThe client reports a mild metallic taste in the mouth病人報告口中出現輕微金屬味
— Explanation · 中文詳解 —
萬古黴素輸注常見「紅人症候群（Red Man Syndrome）」，表現為臉部與上半身潮紅，通常是輸注速度過快引起，處理方式為減慢速度。然而，若出現低血壓（A選項），則屬於嚴重的過敏性休克徵象，必須立即停止輸注並啟動緊急處理措施。
While flushing indicates Red Man Syndrome, which is managed by slowing the infusion, a significant drop in blood pressure suggests a severe anaphylactic reaction. This life-threatening complication requires the nurse to immediately stop the vancomycin infusion and initiate emergency protocols.
✦ 台美臨床差異
兩地針對紅人症處置原則一致，但在美國護理師常有權自行調整輸注速率，台灣則較常遵循醫囑調整速率。