— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人接受靜脈輸注萬古黴素，滴注不久後出現臉部、頸部及胸部潮紅。護理師應優先採取何項措施？
A client is prescribed intravenous vancomycin. The nurse observes flushing of the face, neck, and chest shortly after the infusion begins. Which action should the nurse take first?
- ASlow the infusion rate✓ 正解減慢輸注速率
- BAdminister an antihistamine給予抗組織胺
- CDiscontinue the infusion停止輸注
- DNotify the healthcare provider通知醫療提供者
— Explanation · 中文詳解 —
此臨床表現為紅人症候群（Red Man Syndrome），源於萬古黴素滴注過快引起的組織胺釋放。此現象通常非過敏性休克，首要處置是減慢輸注速度。若減速後症狀仍持續或惡化，才需考慮暫停滴注或通知醫師。抗組織胺僅在醫師醫囑下給予。
The client is experiencing Red Man Syndrome, a histamine-mediated reaction caused by rapid vancomycin infusion, which presents as flushing of the face, neck, and chest. The priority nursing intervention is to slow the infusion rate, as this typically resolves the symptoms without discontinuing the medication. Discontinuation or notifying the provider is reserved for severe or anaphylactic reactions.
✦ 台美臨床差異
台美皆視此為常見藥物不良反應，但美國護理師常依規範自行調降速度，台灣則視醫院給藥流程而定。