— 基本照護與舒適 · HARD · MCQ —
一位經尿道攝護腺切除術後（TURP）的病人，正在進行持續性膀胱沖洗（CBI）。護理師應優先評估什麼？
A nurse is caring for a client with a continuous bladder irrigation (CBI) post-TURP. What should the nurse prioritize in the assessment?
- AThe clarity and color of the urinary output✓ 正解尿液排出物的清澈度與顏色。
- BThe client's ability to void spontaneously患者自主排尿的能力。
- CThe amount of oral fluid intake口服液體的攝取量。
- DThe client's level of pain患者的疼痛程度。
— Explanation · 中文詳解 —
TURP 後最危險的併發症是出血導致血塊堵塞管路。CBI 的目的就是預防血塊堆積。觀察引流液的顏色與清澈度（確認是否有鮮紅血塊）是防止膀胱破裂與阻塞的關鍵，因此為優先評估事項。D、C、B 雖重要，但相較於急性管路阻塞之生命徵象與引流效能，其危急程度較低。
The priority assessment for a client with continuous bladder irrigation post-TURP is monitoring the clarity and color of urinary output to detect hemorrhage or clot formation. Preventing catheter obstruction is critical to avoid bladder distention and rupture, making this assessment more urgent than pain management or spontaneous voiding capability.
✦ 台美臨床差異
美國護理師在 CBI 管理上有極高的自主權（調整流速）；台灣多需依醫師設定之流速為準，護理自主調整空間較小。