一位病人在接受經尿道攝護腺切除術（TURP）後正在進行連續膀胱沖洗（CBI）。護理師發現引流液變為鮮紅色並含有大量血塊。護理師應首先採取哪項措施？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The nurse notes that the drainage has become bright red with numerous large clots. Which action should the nurse take first?
- ANotify the healthcare provider immediately立即通知醫療提供者
- BIncrease the rate of the irrigation fluid✓ 正解增加沖洗液的流速
- CManually irrigate the catheter with sterile normal saline以無菌生理食鹽水手動沖洗導尿管
- DCheck the client's blood pressure and pulse檢查病人的血壓和脈搏
TURP 術後護理的核心在於維持尿管通暢並監測出血。當引流液變為鮮紅色或出現血塊時，首要動作是加快 CBI 的流速，利用持續流動的液體稀釋血液並防止血塊堵塞導尿管。若導尿管被血塊堵塞，膀胱會過度充盈導致疼痛及反射性出血加劇。如果加快流速後情況未改善，才考慮手動沖洗（需醫囑或特定 protocol）或通知醫師。此題考驗的是優先順序中的「預防併發症」與「立即處置」。臨床上，鮮紅色引流代表動脈出血，加快沖洗是為了防止血栓閉塞管路。隨後需評估病人生命徵象以排除低血容休克的風險。這符合 NCLEX 的安全有效照護原則，即先嘗試非侵入性或預防性措施來穩定現狀。
The core of nursing care after TURP focuses on maintaining catheter patency and monitoring for bleeding. When drainage becomes bright red or contains clots, the first action is to increase the rate of the CBI to dilute the blood with continuous flow and prevent clots from obstructing the catheter. If the catheter becomes obstructed by clots, the bladder will become overdistended, causing pain and reflex worsening of bleeding. If conditions do not improve after increasing the rate, manual irrigation (with a physician's order or per protocol) or notification of the provider should then be considered. This question tests prioritization between preventing complications and immediate intervention. Clinically, bright red drainage suggests arterial bleeding, and increasing the irrigation rate helps prevent clot-related obstruction. Vital signs must then be assessed to rule out hypovolemic shock. This follows NCLEX safe and effective care principles, which is to first attempt non-invasive or preventive measures to stabilize the current situation.
在美國，CBI 的流速調整通常由護理師根據引流液顏色自主判斷（Titrate to maintain light pink drainage）；在台灣，雖然護理師也會調整，但通常會在記錄中註明或在交班時強調，且對於手動沖洗管路的醫囑規範較為嚴格。