護理師照護一位留置導尿管的病人。下列哪項觀察需立即採取介入措施？
A nurse is caring for a client with an indwelling urinary catheter. Which of the following observations requires immediate intervention?
- AThe drainage bag is resting on the floor✓ 正解引流袋放置於地面
- BUrine is amber-colored and clear尿液呈琥珀色且清澈
- CThe urine output is 40 mL per hour尿液輸出量為每小時 40 毫升
- DThe tubing is secured to the client's thigh導尿管固定於病人大腿上
留置導尿管的照護重點在於維持引流系統的低重力引流與封閉性。將引流袋放在地上不僅容易被污染，更會因高度高於膀胱而導致尿液逆流，這是造成導尿管相關尿路感染（CAUTI）的主要風險因子。護理人員在進行床邊評估時，必須隨時檢查管路固定與引流袋懸掛狀態。一旦發現引流袋放置於地面，應立即採取介入行動，保護病人免於醫源性感染。
Care of an indwelling urinary catheter centers on maintaining low gravity drainage and a closed system. Placing the drainage bag on the floor not only exposes it to contamination but also positions it above the bladder, allowing urine to reflux. This is a leading risk factor for catheter-associated urinary tract infection (CAUTI). During bedside assessment, the nurse must routinely check tube securement and the placement of the drainage bag. As soon as the drainage bag is found on the floor, the nurse should intervene immediately to protect the client from a healthcare-associated infection.