護理師正給予萬古黴素（vancomycin）的靜脈輸注。病人出現全身搔癢性皮疹和臉部潮紅。護理師應預期採取下列哪些措施？（選所有適合的）
A nurse is administering an IV infusion of vancomycin. The client develops a generalized itchy rash and facial flushing. The nurse should anticipate which of the following actions? (Select all that apply.)
- AStop the vancomycin infusion.✓ 正解停止萬古黴素輸注。
- BAdminister an antihistamine.✓ 正解給予抗組織胺。
- CIncrease the infusion rate.增加輸注速率。
- DNotify the physician.✓ 正解通知醫師。
- EAdminister a bolus of normal saline.給予生理食鹽水推注。
病人出現全身搔癢與臉部潮紅，明確為萬古黴素導致的紅人症候群（Red Man Syndrome）。這是因為藥物輸注過快導致組織胺大量釋放。護理標準程序為：立即停止輸注（移除刺激源）、通知醫師（評估嚴重度）、並給予抗組織胺（如 Diphenhydramine）以拮抗組織胺引發的症狀。此時絕對不可加速輸注，否則會加劇反應。
The client is experiencing Red Man Syndrome, a histamine-mediated reaction caused by rapid vancomycin infusion, characterized by flushing and pruritus. The nurse must immediately stop the infusion to halt further histamine release and notify the provider for further management. An antihistamine should be administered to alleviate symptoms, and the infusion rate should never be increased during a reaction.