護理師為一位 60 歲男性以左側臥 Sims' 位執行大量溫水灌腸。灌注約 2 分鐘後病人突然抓握床欄、冒汗、主訴劇烈腹部痙攣。護理師首要行動為何？
The nurse is administering a large-volume tap water enema to a 60-year-old male in the left lateral Sims' position. About 2 minutes into the instillation, the client suddenly grips the bedrails, sweats, and reports severe abdominal cramping. What is the nurse's first action?
- ARaise the enema bag higher to use gravity to overcome the cramping.升高灌腸袋以利用重力克服痙攣。
- BInstruct the client to bear down (Valsalva) to push the fluid past the blockage.指示病人用力（Valsalva 動作）以將液體推過阻塞處。
- CBriefly clamp the tubing or lower the enema bag to slow the flow, and instruct deep breathing.✓ 正解暫時夾住管路或降低灌腸袋以減慢流速，並指示深呼吸。
- DImmediately remove the enema tube to prevent bowel perforation.立即移除灌腸管以防止腸穿孔。
灌腸時的腹部痙攣是常見、預期中的腸道平滑肌反應，非穿孔徵兆。 選項 C 正確：暫時夾管或降低灌腸袋減緩流速，並指導深呼吸放鬆，痙攣緩解後可恢復灌注。 選項 D 錯誤：拔除管子無法解決便秘。 選項 B 錯誤：用力會增加腹壓，可能造成穿孔。 選項 A 錯誤：升高灌腸袋會加快流速、加重痙攣。
Abdominal cramping during enema is a common expected smooth muscle response, not a perforation sign. C correct: Briefly clamp tubing or lower the bag to slow flow, and coach slow deep breathing. Resume instillation when cramping resolves. A incorrect: Removing the tube doesn't resolve the constipation. B incorrect: Bearing down increases abdominal pressure and risks perforation. D incorrect: Raising the bag increases flow and worsens cramping.
世界通用的基礎護理學技術原則。碰到灌腸時肚子痛，標準解法＝暫時夾起來（Clamp）或是把點滴架放低（Lower the bag）。這題是各國護理考照題庫必備的超高頻萬年考古題。