— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位使用連續膀胱沖洗（CBI）的病人，下列哪些照護措施是必要的？（選所有適合的）
Which of the following interventions are essential for the care of a client with a continuous bladder irrigation (CBI) system? (Select all that apply.)
- AMonitor for bright red urine drainage✓ 正解監測是否有鮮紅色尿液引流
- BKeep the irrigation fluid bag full to prevent air entry✓ 正解保持沖洗液袋充滿以防止空氣進入
- CCalculate the net fluid balance by subtracting output from intake✓ 正解通過從攝入量中減去排出量來計算淨液體平衡
- DDiscontinue the irrigation if the output is pinkish如果引流液呈粉紅色則停止沖洗
- EEnsure the drainage tubing is free from kinks✓ 正解確保引流管路無扭曲
— Explanation · 中文詳解 —
持續性膀胱沖洗（CBI）系統旨在預防攝護腺手術後血塊堵塞尿管。護理措施包括：監測尿液顏色（評估出血量）、保持沖洗液持續流動（防阻塞與空氣進入）、精確計算淨平衡（Net balance，反映膀胱功能）。管路通暢是關鍵，一旦發現顏色異常或引流困難，應檢查管路有無扭曲或阻塞。粉紅色尿液是預期的，不應擅自停止。
Essential interventions include monitoring for bright red drainage to detect hemorrhage, keeping the irrigation bag full to prevent air entry, and calculating net fluid balance to assess true urine output. Additionally, ensuring drainage tubing is free from kinks prevents obstruction and bladder distention.