— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師在給予病人萬古黴素（Vancomycin）時，應執行哪些護理措施？（選所有適合的）
Which of the following interventions should a nurse implement when administering vancomycin to a client? (Select all that apply.)
- AInfuse the medication over at least 60 minutes✓ 正解至少於 60 分鐘內輸注藥物
- BMonitor serum trough levels before the scheduled dose✓ 正解在預定劑量前監測血清波谷濃度
- CAssess the client's hearing for signs of ototoxicity✓ 正解評估病人聽力是否有耳毒性的徵象
- DDiscontinue the infusion immediately if hypotension occurs✓ 正解若發生低血壓則立即停止輸注
- EFlush the IV line with heparin before starting開始前以肝素沖洗靜脈管路
— Explanation · 中文詳解 —
萬古黴素具備腎毒性與耳毒性，給藥期間需嚴格控制輸注時間以防紅人症候群（Red Man Syndrome）。監測波谷濃度（Trough level）以調整劑量是臨床標準。若輸注過程發生血壓下降，應立即停止。E 選項錯誤，IV 線路 Flush 使用生理食鹽水即可，不需特別使用肝素。
Vancomycin should be infused over at least 60 minutes to prevent Red Man Syndrome, and serum trough levels must be monitored to ensure efficacy and prevent toxicity. Nurses should also assess for ototoxicity and discontinue the infusion immediately if hypotension occurs.
✦ 台美臨床差異
台美臨床對於萬古黴素的監測皆非常嚴謹，美國護理師常直接執行採血單，台灣則需由醫師開立採血醫囑。