— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師準備對多位病人給藥，下列哪些病人應優先照顧？（選所有適合的）
A nurse is preparing to administer several medications to a client. Which of the following clients should the nurse prioritize? (Select all that apply.)
- AA client receiving IV vancomycin who reports itching and flushing✓ 正解接受靜脈注射萬古黴素並主訴搔癢和臉紅的病人
- BA client with diabetes scheduled for insulin before breakfast預定在早餐前注射胰島素的糖尿病患者
- CA client receiving heparin with a partial thromboplastin time (PTT) of 95 seconds✓ 正解接受肝素治療且部分凝血活酶時間（PTT）為95秒的病人
- DA client complaining of mild headache after an antihypertensive dose服用降血壓藥後抱怨輕微頭痛的病人
- EA client whose nasogastric tube is blocked during medication administration給藥期間鼻胃管阻塞的病人
— Explanation · 中文詳解 —
優先順序應考量病人安全與潛在的過敏或出血風險。選項 A（萬古黴素造成紅人症）需立即評估有無過敏休克；選項 C（PTT 95 秒，正常值約 25-35 秒，治療範圍通常為 1.5-2.5 倍，故大於 80-90 秒即有出血風險）顯示治療過量，需緊急處理。其餘選項屬於常規用藥或輕微反應，可安排在穩定危急病人後處理。
Clients reporting itching and flushing during vancomycin infusion may be experiencing Red Man Syndrome or anaphylaxis, requiring immediate assessment. Additionally, a PTT of 95 seconds indicates excessive anticoagulation with heparin, posing a high risk for bleeding that necessitates urgent intervention.
✦ 台美臨床差異
台美護理師皆需運用 ABC 原則與危急值通報系統判定優先順序。