— 照護管理 · MEDIUM · MCQ —
護理師督導一位新進護理師照顧使用連續膀胱沖洗（CBI）的病患，下列哪項行動需要護理師介入糾正？
A nurse is supervising a newly licensed nurse who is caring for a client with a continuous bladder irrigation (CBI). Which action by the new nurse requires intervention?
- AAdjusting the irrigation rate to keep the urine light pink調整沖洗速率以保持尿液呈淡粉紅色
- BCalculating the net output by subtracting irrigation volume from total output透過從總排出量中減去沖洗液體量來計算淨排出量
- CEmptying the drainage bag only when it is completely full✓ 正解僅在引流袋完全充滿時才排空
- DUsing sterile technique for every irrigation tubing change每次更換沖洗管路時均使用無菌技術
— Explanation · 中文詳解 —
CBI 系統需要維持密閉且通暢。若引流袋過滿，會導致引流管阻塞或逆流，進而造成膀胱脹大與感染。應定期清空引流袋，而非等到滿溢。其他選項皆為維持 CBI 正確運作的關鍵步驟，能確保液體流動無礙並監測正確出血量。
Drainage bags should be emptied before they become completely full to prevent backflow of urine into the bladder, which increases infection risk and may obstruct the system. Proper continuous bladder irrigation requires maintaining a closed system with accurate output monitoring and sterile technique during changes. Allowing the bag to overflow compromises patient safety and irrigation efficacy.
✦ 台美臨床差異
美國護理單位對 CBI 管路護理有嚴格的無菌規範；台灣臨床有時受限於人力，清潔維護強度較為彈性。