一位接受攝護腺切除術（TURP）的病人正進行連續膀胱沖洗（CBI），護理師發現引流液變成鮮紅色且有大血塊，優先採取的護理措施為何？
A nurse is caring for a client with a continuous bladder irrigation (CBI) system following a TURP. The nurse notes the drainage has turned bright red with large clots. What is the priority nursing action?
- AIncrease the irrigation flow rate✓ 正解增加沖洗流速
- BAdminister an ordered analgesic給予處方止痛藥
- CDocument the findings in the chart在病歷中記錄發現
- DNotify the surgeon immediately立即通知外科醫師
出現鮮紅色引流液與血塊表示管路可能阻塞，優先處理是增加沖洗速度以排除血塊，避免膀胱過度脹大引起劇痛或繼發性出血。若增加速度後仍未改善，才需要通知醫師介入，此時 ABC 原則中的 Circulation (出血控制) 為首要考慮。
The appearance of bright red drainage with large clots indicates that the tubing may be obstructed. The priority action is to increase the irrigation flow rate to flush out the clots and prevent bladder over-distention, which can cause severe pain or secondary hemorrhage. Only if irrigation does not improve the situation should the surgeon be notified. In this scenario, Circulation (hemorrhage control) under the ABC principle is the primary consideration.
美國護理師常依據預設的 protocol 自行調整沖洗速度；台灣護理師通常需先聯絡醫師或依照個別術後醫囑設定，較少主動自行大幅調整。