— 藥理與非經腸給藥 · HARD · MCQ —
護理師正為病人施打萬古黴素（Vancomycin），發現病人的臉部、頸部及胸部出現潮紅與發紅。護理師的優先處置為何？
A nurse is administering a dose of vancomycin to a client. The nurse notices the client's face, neck, and chest have become flushed and red. What is the nurse's priority action?
- ANotify the provider for an order for epinephrine通知醫師開立腎上腺素醫囑
- BAdminister an antihistamine immediately立即給予抗組織胺
- CDiscontinue the infusion entirely完全停止輸注
- DSlow the rate of the infusion✓ 正解減慢輸注速率
— Explanation · 中文詳解 —
此徵象為典型的「紅人症候群」（Red Man Syndrome），是萬古黴素輸注速度過快引起的組胺釋放反應。處理原則是先減慢輸注速度或暫停，待症狀緩解後再調整速度重新給藥。這並非真正的過敏反應，因此不需要立即注射腎上腺素或抗組織胺。
The symptoms describe Red Man Syndrome, a histamine release reaction due to rapid vancomycin infusion, so the priority action is to slow the infusion rate. This condition is not a true allergy, so epinephrine is not indicated, and complete discontinuation is unnecessary unless severe hypotension occurs.
✦ 台美臨床差異
兩地對紅人症候群的處置準則皆為優先減速，但在評估是否需要暫停輸液的判斷上，美國護理師依 protocol 執行權限較大。