— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正為病人靜脈輸注萬古黴素（Vancomycin）。哪項觀察結果需要立即處理？
A nurse is administering a dose of intravenous vancomycin to a client. Which observation requires immediate intervention?
- AMild itching of the infusion site輸注部位輕微發癢
- BFlushing of the face, neck, and upper chest✓ 正解臉部、頸部和上胸部潮紅
- CBlood pressure reading of 120/80 mmHg血壓讀數為 120/80 mmHg
- DThe client reports a metallic taste病人報告有金屬味
— Explanation · 中文詳解 —
輸注萬古黴素若速度過快，易引發紅人症候群（Red Man Syndrome），表現為臉部、頸部及胸部上方潮紅、發癢。處理原則應為立即暫停輸注並通知醫師，通常重新評估輸注速度即可解決。其他選項如金屬味或正常血壓皆非緊急臨床危險信號。
Facial, neck, and upper chest flushing indicates Red Man Syndrome, a reaction caused by rapid vancomycin infusion due to histamine release. This condition requires immediate intervention, such as stopping the infusion and notifying the provider, to prevent progression to hypotension or respiratory distress. Other symptoms like mild itching or metallic taste are less urgent or normal side effects.
✦ 台美臨床差異
台美皆強調萬古黴素輸注需至少 60 分鐘以預防此症狀，但在美國護理師權限內可直接減慢速度，台灣則常需確認醫囑。