— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位尿滯留的病人。哪項措施是優先事項？
A nurse is caring for a client with urinary retention. Which action is the priority?
- AAssess the bladder for distention and perform a bladder scan✓ 正解評估膀胱是否有脹滿並進行膀胱掃描
- BEncourage the client to drink more fluids鼓勵病人多攝取液體
- CCall the physician for a catheterization order immediately立即請醫師開立導尿医嘱
- DAdminister an analgesic for pain給予止痛藥以緩解疼痛
— Explanation · 中文詳解 —
尿滯留病人首重評估膀胱充盈程度。膀胱掃描儀（Bladder scan）是非侵入性且迅速的工具，可精確評估餘尿量，據此決定是否需要留置導尿。先止痛或強迫飲水會增加膀胱壓力，未經評估直接導尿則可能不必要。
For a client with urinary retention, the priority is to assess the degree of bladder distention. A bladder scanner is a non-invasive and rapid tool that can accurately determine residual urine volume, on the basis of which the need for catheterization can be decided. Giving analgesics or forcing fluids would increase bladder pressure, and catheterizing without assessment may be unnecessary.
✦ 台美臨床差異
美台臨床皆強調 bladder scan 的使用，但美國護理師常具備執行掃描的資格與權限，台灣實務常需醫師或訓練過的護理師執行。