— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正以 60 分鐘滴注時間，靜脈輸注 1 g 萬古黴素（vancomycin）。輸注期間，病人臉頸部出現紅色、搔癢的皮疹，並表示臉部發紅。首要的護理措施為何？
A nurse is administering vancomycin 1 g IV piggyback over 60 minutes. During the infusion, the client develops a red, itchy rash on their face and neck and reports feeling flushed. What is the priority nursing action?
- AStop the infusion and notify the physician.✓ 正解停止輸注並通知醫師
- BAdminister an antihistamine and continue the infusion.給予抗組織胺並繼續輸注
- CAdminister a dose of acetaminophen.給予一劑乙醯胺酚
- DIncrease the infusion rate to administer the remaining dose faster.增加輸注速率以更快速給予剩餘劑量
— Explanation · 中文詳解 —
萬古黴素（Vancomycin）輸注過快常導致組織胺大量釋放，引發「紅人症候群」（Red Man Syndrome）。其症狀包括顏面、頸部與上軀幹的潮紅、搔癢及低血壓。首要護理動作為立即停止輸注，以阻止症狀惡化。隨後應通知醫師，並根據醫囑可能需要抗組織胺藥物或減慢後續輸注速率。切勿自行決定繼續輸注或單純給藥，必須先中斷刺激源。
The client is experiencing Red Man Syndrome, a histamine-mediated reaction caused by rapid vancomycin infusion. The priority nursing action is to stop the infusion immediately to prevent further release of histamine and worsening of symptoms, then notify the provider.