# A nurse is caring for a client prescribed Vancomycin. Which nursing action is most appropriate regarding infusing over at least 60 minutes to prevent Red Man Syndrome and monitoring trough levels?

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> language: zh-TW  
> subject: NCLEX-RN  
> category: PPT

## 題目

A nurse is caring for a client prescribed Vancomycin. Which nursing action is most appropriate regarding infusing over at least 60 minutes to prevent Red Man Syndrome and monitoring trough levels?

## 選項

1. Monitor vital signs and assess laboratory values prior to administration.
2. Administer the medication with a full glass of water every morning. **✔ 正確答案**
3. Instruct the client to report any unexpected side effects immediately.
4. Verify the prescription details with the healthcare provider.

**正確答案: 2**

## 解析

When administering Vancomycin, key nursing considerations include monitoring patient status, checking critical laboratory values, and providing appropriate safety education. Unsafe practices such as stopping medications abruptly or doubling missed doses are incorrect.

## 深入解析

1. Scenario: Patient taking Warfarin.
2. Recognize Cues: Evaluate INR 모니터링 및 비타민 K 음식 규칙적 섭취.
3. Take Action: Ensure safe administration protocols.
4. Evaluate: Re-assess therapeutic response.

## 重要概念

- **Warfarin (와파린)** — 항응고제로 출혈 징후를 모니터링하고 비타민 K가 풍부한 시금치 등은 일정하게 섭취해야 해요.

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