— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正給予萬古黴素（vancomycin）的靜脈輸注。病人出現發燒和畏寒。首要的護理措施為何？
A nurse is administering an IV infusion of vancomycin. The client develops fever and chills. What is the priority nursing action?
- AIncrease the infusion rate.加快輸注速度
- BAdminister acetaminophen.給予乙醯胺酚
- CStop the infusion and notify the physician.✓ 正解停止輸注並通知醫師
- DObtain blood cultures.抽取血液培養
— Explanation · 中文詳解 —
萬古黴素（Vancomycin）輸注期間若出現發燒、畏寒，需考量兩種可能：嚴重的輸注相關反應（Infusion-related reaction）或急性過敏性休克（Anaphylaxis）。基於安全原則（Safety Principle），在無法排除藥物不良反應的情況下，護理師必須立刻停止輸注，以中斷過敏原的攝入，隨後進行生命徵象評估並通知醫師，這是 NCLEX 處理輸注反應的標準程序（Priority Action）。
When a client develops fever and chills during vancomycin infusion, the priority action is to stop the infusion immediately to prevent worsening of a potential severe reaction or anaphylaxis. After stopping the infusion, the nurse should assess vital signs and notify the provider.