— 基本照護與舒適 · MEDIUM · MCQ —
護理師觀察到哪項評估結果，顯示病人的留置導尿管可能有阻塞？
Which assessment finding indicates to the nurse that a client's urinary catheter may be obstructed?
- APresence of sediment in the tubing管路中有沉澱物
- BDark amber urine in the bag集尿袋中有深琥珀色尿液
- CUrine leakage around the catheter✓ 正解導尿管周圍有尿液滲漏
- DPatient reports mild pelvic discomfort病人報告輕微骨盆不適
— Explanation · 中文詳解 —
當導尿管阻塞時，尿液無法經管路排出，導致膀胱積尿，進而由導尿管周圍溢出。尿色深（B）通常反映水分攝取不足；輕微不適（D）需鑑別；沈澱物（A）雖易致阻塞，但非阻塞本身的確切徵兆。尿液從周圍滲出是管路功能失效的典型表現。
When an indwelling urinary catheter is obstructed, urine cannot drain through the tubing, causing urinary retention in the bladder and resulting in leakage around the catheter. Dark urine (B) usually reflects inadequate fluid intake; mild discomfort (D) requires further differentiation; sediment (A), while a risk factor for obstruction, is not itself a definitive sign of obstruction. Leakage around the catheter is the classic manifestation of catheter dysfunction.
✦ 台美臨床差異
台美臨床對於導尿管護理的無菌原則一致，但美國更強調及早拔除以預防 CAUTI。