— 降低風險 · MEDIUM · MCQ —
護理師照護一位經尿道攝護腺切除術（TURP）後進行連續膀胱沖洗（CBI）的病人。哪一項發現需要立即介入？
A nurse is caring for a client with a continuous bladder irrigation (CBI) after transurethral resection of the prostate (TURP). Which finding requires immediate intervention?
- AClient reports a feeling of bladder fullness病人報告膀胱飽脹感
- BPresence of small blood clots in the tubing管路中存在少量血塊
- CThe urine in the drainage bag is pink-tinged引流袋中的尿液呈粉紅色
- DOutput is less than input✓ 正解輸出量少於輸入量
— Explanation · 中文詳解 —
CBI 的目的是防止血塊阻塞尿道。如果尿液輸出量少於輸入的沖洗液量，代表引流受阻，膀胱內液體滯留，可能導致膀胱脹大、壓力增加甚至造成手術切口出血或膀胱破裂。這是需要立即排除阻塞（手動沖洗）的緊急狀況。
The purpose of CBI is to prevent obstruction of the urethra by clots. If urinary output is less than the volume of irrigation fluid infused, drainage is obstructed and fluid is retained in the bladder, which can lead to bladder distention, increased pressure, and even bleeding from the surgical site or bladder rupture. This is an emergency that requires immediate relief of the obstruction (manual irrigation).
✦ 台美臨床差異
美國護理師常有權限執行初步手動沖洗來排除血塊；台灣部分醫院依據單位規定可能需先確認醫囑或由醫師協助。