— 降低風險 · MEDIUM · MCQ —
護理師照護一位接受經尿道前列腺切除術後進行連續膀胱沖洗的病人。下列哪項觀察需立即介入？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which observation requires immediate intervention?
- AOutput appears viscous with large clots and no drainage✓ 正解引流液呈黏稠狀且有大血塊，無引流
- BPatient reports bladder spasms病人主訴膀胱痙攣
- CThe irrigation fluid is flowing continuously沖洗液持續流動
- DOutput is bright red with small clots引流液呈鮮紅色且有小血塊
— Explanation · 中文詳解 —
TURP 術後連續膀胱沖洗（CBI）的目的是防止血液凝塊阻塞尿管。若引流液呈現黏稠狀、伴隨大量血塊，且「完全沒有引流排出」，代表導尿管已嚴重阻塞。這會導致膀胱過度膨脹（Bladder distention），造成劇烈膀胱痙攣、出血加劇，甚至膀胱破裂，必須立即手動沖洗（Manual irrigation）以清除阻塞。
Immediate intervention is required if there is no drainage despite viscous output and large clots, as this indicates catheter obstruction and potential bladder distension. This situation poses a risk of severe spasms and hemorrhage, necessitating prompt manual irrigation to restore patency.