# 一位接受 IV vancomycin 的個案在輸注期間出現頸部及上軀幹潮紅。下列哪項護理行動最為適當？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397134&lang=zh-tw  
> language: zh-TW  
> subject: Medication Administration  
> category: PPT

## 題目

一位接受 IV vancomycin 的個案在輸注期間出現頸部及上軀幹潮紅。下列哪項護理行動最為適當？

## 選項

1. 加快輸注速度以盡快輸注完畢。
2. 將此發現記錄為預期的治療反應。
3. 準備給予血栓溶解劑。
4. 停止或減慢輸注，並依標準程序通知醫師。 **✔ 正確答案**

**正確答案: 4**

## 解析

vancomycin 輸注期間出現潮紅，暗示可能發生輸注相關反應，應透過停止或減慢輸注並遵循標準程序來處理。加快輸注速度可能使症狀惡化。此發現並非治療效果，也與血栓溶解治療無關。

## 深入解析

臨床判斷
運用個案線索、時間點、檢驗數據及安全風險，選擇最符合 Vancomycin 輸注反應的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
針對 Vancomycin 輸注反應，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **Vancomycin** — 一種常用於治療嚴重革蘭氏陽性菌感染的抗生素。
- **輸注反應** — 在給藥期間發生的反應，可能與輸注速度有關。
- **標準程序** — 經核准的機構流程，用以指導臨床行動。

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_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_