— 藥理與非經腸給藥 · EASY · MCQ —
護理師正在為病人靜脈輸注萬古黴素（Vancomycin），發現病人臉部、頸部及上胸部潮紅。護理師應優先採取哪項行動？
A nurse is administering IV vancomycin to a client. The nurse notices the client's face, neck, and upper chest are flushing. Which action should the nurse take first?
- ANotify the healthcare provider通知醫療保健提供者
- BSlow the rate of infusion減慢輸注速度
- CStop the infusion immediately✓ 正解立即停止輸注
- DAdminister an antihistamine給予抗組織胺
— Explanation · 中文詳解 —
Vancomycin 引起的 Red Man Syndrome（RMS）為非過敏性組織胺釋放反應，臨床判斷分兩層次：(1) 若僅見潮紅、輕度搔癢且生命徵象穩定 → 可先「減慢輸注速率」並給予 antihistamine；(2) 若伴隨低血壓、喘鳴或呼吸窘迫（過敏性休克徵象） → 必須「立即停止輸注」並啟動急救。本題病人僅描述臉部、頸部與胸部紅疹，未提及生命徵象異常，現代指引上『立即停止』與『減慢』皆為可接受答案，本題以『立即停止』作為較保守的安全選擇。
The nurse should stop the infusion immediately, as this is the most conservative safety action when Red Man Syndrome occurs. Although slowing the rate is sometimes acceptable for mild symptoms, stopping the infusion ensures patient safety while the reaction is assessed.
✦ 台美臨床差異
台美臨床皆將紅人症候群視為輸注反應，護理師依 protocol 暫停給藥後通報是標準規範。