— 降低風險 · MEDIUM · MCQ —
護理師照護一位經尿道攝護腺切除術後接受連續膀胱沖洗的病人，發現何種狀況需立即通知醫師？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which observation should the nurse report to the provider immediately?
- AThe outflow is bright red with thick clots✓ 正解排出液呈鮮紅色並伴有厚實血塊
- BThe client reports a feeling of fullness in the bladder病人主訴膀胱有脹滿感
- CThe drainage bag is empty after two hours兩小時後引流袋為空
- DThe irrigation fluid is light pink in color沖洗液呈現淡粉紅色
— Explanation · 中文詳解 —
TURP 術後出現鮮紅色血尿且含有大量血塊，顯示有活動性出血。輕微粉紅色是術後常見現象。若排出液量少於灌注量，代表引流受阻或膀胱脹大，雖需處理但大量鮮紅血塊反映出血速度快，威脅病人的循環穩定，應為優先回報事項。
After TURP, bright red drainage with thick clots indicates active bleeding and must be reported immediately. Light pink fluid is expected. Bladder fullness or low drainage may indicate obstruction and requires intervention, but frank hemorrhage threatens hemodynamic stability and is the priority.
✦ 台美臨床差異
美國護理師依權限常可直接執行手工沖洗（manual irrigation）排除血塊；台灣部分醫院依規範仍多需先評估並請醫師確認。