— 照護管理 · MEDIUM · MCQ —
護理師督導新進護理師執行導尿管插入。哪項行動需要即時介入？
A nurse is supervising a newly licensed nurse who is inserting an indwelling urinary catheter. Which action by the new nurse requires intervention?
- ACleansing the meatus with betadine before insertion在插入前使用優碘清潔尿道口
- BSecuring the catheter to the client's thigh將導尿管固定於病人大腿
- CUsing a sterile technique throughout the procedure整個程序使用無菌技術
- DInflating the balloon before confirming urine flow✓ 正解在確認尿液流出前充氣水囊
— Explanation · 中文詳解 —
導尿管插入是一項無菌操作（Sterile technique）。關鍵技術點在於確認導尿管前端已完全進入膀胱，通常表現為尿液回流，此時才能充盈水球（Balloon inflation）。若未確認尿液回流即充盈水球，水球會在尿道中膨脹，造成尿道撕裂與永久性損傷，這是嚴重的護理技術錯誤，督導者必須立即介入。
Urinary catheterization is a sterile procedure. The key technical point is to confirm that the catheter tip has fully entered the bladder—usually demonstrated by urine return—before inflating the balloon. If the balloon is inflated before urine return is confirmed, the balloon will expand within the urethra and cause urethral tearing and permanent injury. This is a serious nursing technique error, and the supervisor must intervene immediately.