護理師照護一位接受經尿道前列腺切除術（TURP）後進行持續膀胱沖洗（CBI）的病人。病人主訴嚴重膀胱痙攣，護理師發現引流袋流出量減少。應優先採取哪項措施？
The nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The client reports severe bladder spasms and the nurse notices reduced outflow in the drainage bag. Which action should the nurse take first?
- AIncrease the flow rate of the irrigation fluid增加沖洗液的流速
- BAdminister the prescribed antispasmodic medication給予處方的解痙藥物
- CCheck the drainage tubing for kinks or clots✓ 正解檢查引流管路是否有扭結或血塊
- DIrrigate the catheter with a sterile syringe using 30-50 mL of saline使用無菌注射器以 30-50 mL 生理食鹽水沖洗導尿管
TURP 術後的 CBI 護理核心是維持引流通暢。當病人出現膀胱痙攣且引流量減少時，首要考慮的是『機械性阻塞』。痙攣通常是因為膀胱內積存了尿液或血塊無法排出，導致膀胱壁過度擴張所致。遵循『最少侵入性優先』原則，護理師應先檢查管路有無受壓、扭曲或摺疊（C）。如果檢查管路後發現無扭曲，下一步才是考慮是否有血塊堵塞，這時可能需要進行手工沖洗（D）。直接給予止痙藥（B）是治標不治本，若阻塞未排除，給藥也無法緩解壓力。增加沖洗液流速（A）只會讓膀胱內積水更多，進一步加劇痙攣與損傷。這題測試的是護理師在面對設備相關併發症時的系統化評估順序。
A high-pressure alarm on a mechanical ventilator typically indicates increased airway resistance, with secretions being the most common cause. The nurse should first assess for and clear airway secretions to ensure patent ventilation and prevent respiratory compromise. While checking for tubing kinks or tension pneumothorax is important, addressing immediate airway obstruction takes precedence.
在美國 NCLEX 邏輯中，檢查管路（Check for kinks）永遠排在手動沖洗（Manual irrigation）之前。在台灣臨床，護理師發現病人疼痛時常會先嘗試擠壓管路（Milking/Stripping，雖現已不建議），或直接進行手動沖洗，但考試時必須記住『先評估外在因素、再採取侵入措施』的準則。