— 藥理與非經腸給藥 · HARD · SATA —
病人正在靜脈輸注萬古黴素（Vancomycin）。護理師應立即向醫師報告哪些發現？（選所有適合的）
A nurse is caring for a client receiving intravenous vancomycin. Which findings should the nurse report to the provider immediately? (Select all that apply.)
- AFlushing of the face and neck✓ 正解臉部和頸部潮紅
- BClient reports severe pruritus on the trunk✓ 正解病人主訴軀幹嚴重搔癢
- CSystolic blood pressure decreased from 120 to 88 mmHg✓ 正解收縮壓從120降至88 mmHg
- DMinimal discomfort at the IV site靜脈注射部位輕微不適
- EWheezing and difficulty breathing✓ 正解喘鳴和呼吸困難
— Explanation · 中文詳解 —
萬古黴素可能導致「紅人症候群」（Red Man Syndrome），表現為臉部潮紅與搔癢，需減緩輸速。若出現低血壓或呼吸窘迫，則屬於過敏性休克徵兆，必須立即停止輸注並給予緊急處理。輕微不適（D）則需評估，但不一定需要立即回報。
The nurse should immediately report facial flushing, severe pruritus, hypotension, and wheezing, as these indicate Red Man Syndrome or potential anaphylaxis requiring intervention such as slowing the infusion or stopping it entirely. Minimal discomfort at the IV site is not an emergency and does not require immediate provider notification compared to systemic reactions.
✦ 台美臨床差異
台灣針對萬古黴素常執行治療性藥物監測（TDM），美國亦同，但重視護理師對輸液過敏反應的警覺性。