— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師準備投予靜脈注射 Vancomycin。應採取哪些措施？（選所有適合的）
A nurse is preparing to administer IV vancomycin. Which actions should the nurse take? (Select all that apply.)
- AMonitor the infusion site for phlebitis✓ 正解監測輸注部位是否有靜脈炎
- BAdminister the dose slowly over at least 60 minutes✓ 正解至少於 60 分鐘內緩慢給予劑量
- CCheck the trough level before the scheduled dose✓ 正解在預定劑量前檢查谷濃度
- DIncrease the infusion rate if the client feels flushed若病人感到潮紅則加快輸注速率
- EAssess the client for red man syndrome during infusion✓ 正解於輸注期間評估病人是否有紅人症
— Explanation · 中文詳解 —
Vancomycin 具刺激性，易引起靜脈炎；投藥過快會導致紅人症（Red Man Syndrome，臉部軀幹潮紅、低血壓）。必須慢速輸注（至少 60 分鐘）。同時，因其具腎毒性與耳毒性，必須在投藥前檢測谷濃度（trough level）以調整劑量。選項 D 錯誤，出現潮紅應減慢或暫停輸注，不可加速。
The nurse should monitor the infusion site for phlebitis, administer vancomycin slowly over at least 60 minutes to prevent red man syndrome, check trough levels to avoid toxicity, and assess for flushing during infusion. Increasing the rate if flushing occurs is incorrect; the infusion should be slowed or stopped instead.
✦ 台美臨床差異
台灣醫院多有明確的 Vancomycin 輸注協定（Protocol），包含監測 trough level 與輸注時間限制。