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藥理與非經腸給藥 · MEDIUM · MCQ

病人正在接受萬古黴素(Vancomycin)靜脈輸注,哪項評估結果需要護理師立即介入?

A client is receiving vancomycin IV. Which assessment finding requires immediate nursing intervention?

  • ABlood pressure 110/70 mmHg
    血壓 110/70 mmHg
  • BSlight nausea during infusion
    輸注期間輕微噁心
  • CUrine output 50 mL/hour
    尿量 50 mL/hour
  • DFlushing of the face, neck, and chest✓ 正解
    臉部、頸部和胸部潮紅
Explanation · 中文詳解

紅人症候群(Red Man Syndrome)為萬古黴素輸注速度過快引起的組胺釋放反應,表現為上半身潮紅、搔癢。護理師應立即減慢或停止輸注並通知醫師。A 為正常範圍;C 為輕微副作用;C 代表腎功能尚可,均非首要處理事項。

Flushing of the face, neck, and chest indicates Red Man Syndrome, a histamine-mediated reaction caused by rapid vancomycin infusion. This condition requires immediate nursing intervention, such as slowing or stopping the infusion and notifying the provider, to prevent progression to severe hypotension or respiratory distress.

✦ 台美臨床差異

台灣護理師執行萬古黴素時,通常會嚴格依照藥學部規範之過敏預防策略執行。

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