— 藥理與非經腸給藥 · HARD · MCQ —
病人正在接受萬古黴素（Vancomycin）靜脈注射。護理師觀察到病人出現低血壓、潮紅，頸部與胸部出現紅疹。首要護理措施為何？
A client is receiving vancomycin IV. The nurse notes the client develops hypotension, flushing, and a rash on the neck and chest. What is the priority nursing intervention?
- AAdminister an antihistamine給予抗組織胺
- BSlow the infusion rate減慢輸注速度
- CNotify the physician通知醫師
- DStop the infusion immediately✓ 正解立即停止輸注
— Explanation · 中文詳解 —
此臨床表現為萬古黴素引起的「紅人症候群」（Red Man Syndrome），是因為輸注速度過快導致組織胺大量釋放。雖然減慢速度有時有效，但在病人出現低血壓（血流動力學不穩定）時，首要動作必須先停止輸注，再進一步評估與處理。
The client is experiencing Red Man Syndrome, characterized by hypotension, flushing, and rash due to rapid histamine release from vancomycin infusion. Because hypotension indicates hemodynamic instability, the priority intervention is to stop the infusion immediately before administering medications or notifying the provider.
✦ 台美臨床差異
美台皆將紅人症候群視為藥物不良反應，護理師依醫囑或 protocol 處理。