— 藥理與非經腸給藥 · MEDIUM · MCQ —
一位病人因嚴重的葡萄球菌感染接受靜脈注射 Vancomycin。下列哪項評估結果需要立即採取護理行動？
A client is prescribed intravenous vancomycin for a severe staphylococcal infection. Which assessment finding requires immediate nursing intervention?
- AThe client develops a flushing rash on the face and neck✓ 正解病人面部與頸部出現潮紅性皮疹
- BThe client experiences pain at the IV insertion site病人經歷靜脈穿刺部位疼痛
- CThe client reports a slight increase in oral temperature病人報告口腔溫度略有升高
- DThe client reports a mild metallic taste in the mouth病人報告口中出現輕微金屬味
— Explanation · 中文詳解 —
紅人症（Red Man Syndrome）是 Vancomycin 滴注過快常見的過敏樣反應，表現為臉、頸、軀幹上部的潮紅、發癢。護理師應立即暫停輸注，這通常與組胺釋放有關，減慢滴注速率或給予抗組胺藥物後可緩解。輕微金屬味屬常見副作用；注射部位疼痛通常為血管刺激，需觀察是否有滲漏；體溫輕微升高可能與感染本身有關。
The development of a flushing rash on the face and neck indicates Red Man Syndrome, a histamine-mediated reaction caused by rapid vancomycin infusion. This finding requires immediate nursing intervention to stop the infusion, as continuing the drug can lead to severe hypotension and cardiovascular collapse.
✦ 台美臨床差異
台美臨床對於 Vancomycin 監測均重視腎功能與藥物血中濃度（Trough level），但美國更強調對給藥速度相關過敏反應的警覺性。