— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師準備給予病人 Vancomycin。下列哪些護理措施有助於預防輸注相關併發症？（選所有適合的）
A nurse is preparing to administer Vancomycin to a client. Which nursing actions are appropriate to prevent infusion-related complications? (Select all that apply.)
- AAdminister the medication over at least 60 minutes✓ 正解以至少 60 分鐘的時間給藥
- BMonitor for flushing, tachycardia, and pruritus✓ 正解監測潮紅、心搏過速及搔癢
- CDilute the medication according to hospital protocol✓ 正解依照醫院規定稀釋藥物
- DAdminister a rapid bolus to ensure therapeutic trough levels快速靜脈推注以確保治療性谷濃度
- EAssess for hypotension during the infusion✓ 正解評估輸注期間是否有低血壓
— Explanation · 中文詳解 —
Vancomycin 若滴注過快易產生紅人症候群（Red Man Syndrome），表現為臉部、頸部潮紅、低血壓、搔癢或心跳過速。因此，必須緩慢輸注（至少 60 分鐘），並監測生命徵象。D 選項錯誤，快速推注會直接引發嚴重的過敏樣反應或組織壞死。
A hemolytic transfusion reaction is indicated by low back pain, chills, fever, hypotension, and hematuria due to red blood cell destruction. These symptoms reflect acute intravascular hemolysis, kidney involvement, and shock, requiring immediate intervention.
✦ 台美臨床差異
美國醫院多使用智慧幫浦設定，台灣臨床則常見護理師手動調整輸注速度，需更留意滴注時間。