# 一位接受 IV vancomycin 的病人在輸注過程中出現臉部及頸部潮紅和搔癢。護理師應採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394082&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

一位接受 IV vancomycin 的病人在輸注過程中出現臉部及頸部潮紅和搔癢。護理師應採取哪項行動？

## 選項

1. 根據政策停止或減慢輸注，並通知醫師。 **✔ 正確答案**
2. 加快輸注速度以更快完成給藥。
3. 將此反應記錄為預期現象，並以相同速度繼續輸注。
4. 下一劑以 IV push 方式給藥。

**正確答案: 1**

## 解析

vancomycin 輸注期間出現潮紅和搔癢，可能表示輸注相關反應。護理師應根據政策停止或減慢輸注，評估病人，並通知醫師。快速輸注可能使反應惡化。

## 深入解析

臨床判斷
藥物反應需要停止來源並評估病人。

記憶提示
Vancomycin 潮紅：減慢或停止，然後通報。

## 臨床情境

臨床實務指引
Vancomycin 應以適當速度輸注，並應監測病人是否有輸注反應和過敏症狀。

注意事項
勿將輸注反應誤認為需要加快給藥速度的理由。

## 重要概念

- **Vancomycin** — 一種用於特定嚴重革蘭氏陽性菌感染的抗生素。
- **輸注反應** — 與靜脈給藥速度或過程相關的反應。
- **搔癢** — 可能發生於過敏或輸注相關反應的搔癢感。

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