病人靜脈輸注萬古黴素時出現臉部、頸部與胸部潮紅。護理師應採取的優先行動為何？
A client is receiving an IV infusion of vancomycin. The nurse observes flushing of the face, neck, and chest. What is the priority nursing action?
- ADiscontinue the medication permanently永久停用該藥物
- BSlow down the rate of the infusion✓ 正解減慢輸注速率
- CAdminister an antihistamine immediately立即給予抗組織胺
- DAssess the client's blood pressure評估病人的血壓
萬古黴素（Vancomycin）輸注過快時，會直接刺激肥大細胞釋放組織胺，導致「紅人症候群（Red Man Syndrome）」。這並非真正的 IgE 介導過敏反應。臨床優先處理原則為減緩輸注速度，通常可緩解症狀。若症狀持續或嚴重，才考慮進一步醫療介入。不需立即停藥，因為這是劑量依賴性反應，而非免疫過敏。
The priority nursing action is to slow down the infusion rate, as the observed flushing indicates Red Man Syndrome caused by rapid histamine release rather than a true allergic reaction. Discontinuing the medication is unnecessary unless severe hypotension or respiratory distress occurs, and antihistamines are reserved for cases where slowing the rate does not resolve symptoms.
美國臨床對於萬古黴素輸注常遵循藥劑部門規範（通常大於 60 分鐘），且護理師在發現紅人症候群時，有權先自行減緩速度並通報醫師，此為 NCLEX 考試中的核心安全護理判斷。