— 降低風險 · MEDIUM · SATA —
護理師照護經尿道攝護腺切除術後，進行持續膀胱沖洗（CBI）的病人，應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse take when caring for a client with a continuous bladder irrigation (CBI) following a TURP procedure? (Select all that apply.)
- AMonitor the color of the drainage output✓ 正解監測引流液顏色
- BAdjust irrigation flow rate to keep urine clear or pink✓ 正解調整沖洗流速以保持尿液清澈或淡粉色
- CClamp the catheter if the patient reports bladder spasms若病人報告膀胱痙攣則夾住導尿管
- DCalculate net fluid balance by subtracting irrigation amount✓ 正解透過減去沖洗液量來計算淨液體平衡
- EEnsure tubing is free of kinks to prevent obstruction✓ 正解確保管路無扭曲以防阻塞
— Explanation · 中文詳解 —
TURP 術後 CBI 的重點在於維持管路通暢與引流液顏色。護理師需監測顏色（A）、調整沖洗速度以維持顏色（B）、計算淨入量（D）、維持管路通暢（E）。C 是錯誤的，痙攣時夾管會導致膀胱內壓升高，加重疼痛與出血，應保持引流。
Post-TURP CBI focuses on patency and drainage color. The nurse monitors color (A), titrates irrigation to keep urine clear/pink (B), calculates net output (D), and ensures patency (E). C is wrong — clamping during spasm raises bladder pressure, worsening pain and bleeding; drainage must be maintained.
✦ 台美臨床差異
美台對 TURP 後照護流程雷同，皆強調病安監測，惟美國護理師依醫囑調整沖洗速度更為普及。