一位接受經尿道攝護腺切除術（TURP）並進行連續膀胱沖洗（CBI）的病人。護理師發現流出量停止，且病人主訴嚴重的膀胱痙攣。護理師應首先採取哪項行動？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The nurse notices that the outflow has stopped, and the client is complaining of severe bladder spasms. What is the first action the nurse should take?
- AIncrease the rate of the continuous irrigation fluid增加連續沖洗液的流速
- BAdminister the prescribed analgesic for pain給予處方止痛藥以緩解疼痛
- CNotify the physician immediately立即通知醫師
- DIrrigate the catheter with 30-50 mL of sterile normal saline✓ 正解以 30-50 mL 無菌生理食鹽水沖洗導尿管
TURP 術後 CBI 的常見併發症是血塊阻塞導尿管。當流出量停止而沖洗液持續進入時，膀胱會過度充盈，引發強烈的膀胱痙攣與疼痛。護理師的第一動作是「解除阻塞」。根據護理常規，應使用無菌生理食鹽水進行手動沖洗（D），以排除血塊或組織碎片。選項 B（給止痛藥）無法解決物理性阻塞，且膀胱持續膨脹可能導致手術部位出血加重；選項 A（增加流速）會讓更多液體進入已阻塞的膀胱，使疼痛與壓力更劇烈，是禁忌；選項 C（通知醫師）應在護理嘗試解除阻塞無效後執行。此題強調護理師解決管路問題的獨立判斷力。
A common complication of CBI after TURP is obstruction of the urinary catheter by blood clots. When outflow stops while irrigation fluid continues to enter, the bladder becomes overdistended, producing intense bladder spasm and pain. The nurse's first action is to relieve the obstruction. According to nursing protocol, the catheter should be manually irrigated with sterile normal saline (D) to clear clots or tissue fragments. Option B (administering an analgesic) does not relieve the physical obstruction, and continued bladder distention may worsen bleeding at the surgical site; option A (increasing the irrigation flow rate) drives more fluid into an already obstructed bladder, intensifying pain and pressure, and is contraindicated; option C (notifying the physician) is performed only after the nurse's attempts to clear the obstruction fail. This item emphasizes the nurse's independent judgment in solving tubing problems.
在美國 NCLEX 邏輯中，護理師被預期具備執行 PRN 醫囑或標準 protocol（如排除導尿管阻塞）的自主性。在台灣，部分醫院可能規定手動沖洗需由醫師執行或在醫師口頭指示下執行，但從考試角度，這屬於護理評估與處置範疇。