— 基本照護與舒適 · MEDIUM · MCQ —
護理師照顧一位術後 8 小時未排尿的病人。護理師應先採取哪項行動？
A nurse is caring for a client who is post-operative and has not voided for 8 hours. What is the first action the nurse should take?
- ANotify the healthcare provider immediately.立即通知醫療保健提供者。
- BIncrease intravenous fluid rate.增加靜脈輸液速率。
- CInsert an indwelling urinary catheter.插入留置導尿管。
- DPerform a bladder scan.✓ 正解進行膀胱掃描。
— Explanation · 中文詳解 —
術後 8 小時未排尿可能與麻醉藥物引起的尿滯留有關。在採取侵入性措施前，應先使用非侵入性的膀胱掃描器（Bladder Scan）評估膀胱內的尿量，以確認是尿液生成減少（腎功能問題）還是尿排出受阻（滯留問題）。
Failure to void within 8 hours postoperatively may be related to urinary retention caused by anesthetic agents. Before resorting to invasive measures, the noninvasive bladder scanner should first be used to assess the urinary volume in the bladder, in order to distinguish between decreased urine production (a renal problem) and impaired urine outflow (a retention problem).
✦ 台美臨床差異
在美國，護理師通常可根據 Standing Order 直接進行膀胱掃描；台灣多數醫院亦有此設備，但部分仍需口頭知會醫師。