— 藥理與非經腸給藥 · HARD · MCQ —
病人正在靜脈輸注萬古黴素 (Vancomycin)。護理師觀察到潮紅、搔癢及低血壓。優先的護理措施為何？
A client is receiving vancomycin IV. The nurse notes flushing, pruritus, and hypotension. What is the priority nursing intervention?
- AAdminister an antihistamine給予抗組織胺
- BDiscontinue the medication immediately立即停止給藥
- CSlow the infusion rate✓ 正解減慢輸注速率
- DAdminister an epinephrine injection給予腎上腺素注射
— Explanation · 中文詳解 —
上述症狀為萬古黴素輸注症候群 (Red Man Syndrome)，源於輸注速度過快引起的組織胺釋放。處置首要為減緩輸注速度，若症狀嚴重則暫停，而非立即停藥（若只是症候群）或給予急救藥物（除非出現過敏性休克）。
The symptoms described indicate Red Man Syndrome, which results from histamine release due to rapid vancomycin infusion. The priority nursing intervention is to slow the infusion rate to reduce histamine release, rather than discontinuing the medication immediately or administering emergency drugs unless anaphylaxis occurs.
✦ 台美臨床差異
台灣與美國對此症候群的處置一致，但在藥物調配上，台灣護理師可能更頻繁與藥師確認稀釋量，以避免局部刺激。