對於尿滯留病人，護理師哪項措施最重要？
Which action by the nurse is essential for a client experiencing urinary retention?
- ARestrict fluid intake to prevent overflow限制水分攝取以防止溢出性尿失禁
- BAssess for bladder distension by palpation✓ 正解透過觸診評估膀胱脹滿情形
- CProvide a warm bath to increase bladder tone提供溫水澡以增加膀胱張力
- DImmediately insert an indwelling urinary catheter立即插入留置導尿管
尿滯留（Urinary retention）病人最優先的護理評估是確認膀胱是否過度膨脹，以評估溢流性尿失禁（Overflow incontinence）或急性尿滯留的嚴重程度。觸診膀胱是無侵入性且迅速的評估方式，能立即判斷膀胱脹大的程度及位置。若膀胱已過度充盈，則後續的導尿處理必須極為謹慎，避免引發排尿後低血壓（Post-obstructive diuresis）。
For a client with urinary retention, the highest priority nursing assessment is to determine whether the bladder is distended, in order to evaluate overflow incontinence or the severity of acute urinary retention. Bladder palpation is a noninvasive, rapid assessment that immediately reveals the degree and location of distention. If the bladder is significantly overdistended, subsequent catheterization must be performed cautiously to avoid post-obstructive diuresis with hypotension.
美國臨床極度重視導尿管相關尿路感染（CAUTI）的預防，對於尿滯留的處理，通常會先嘗試超音波膀胱掃描（Bladder scan）來評估餘尿，而非直接觸診或導尿。台灣臨床有時仍依賴觸診，但在美執業應優先考慮超音波儀器。