— 基本照護與舒適 · HARD · MCQ —
一位使用連續膀胱沖洗（CBI）的病人，優先的護理動作為何？
A nurse is caring for a client with a continuous bladder irrigation (CBI) system. What is the priority nursing action?
- AMonitor the color of the drainage監測引流液的顏色
- BEnsure the drainage bag is always lower than the bladder✓ 正解確保引流袋始終低於膀胱
- CDisconnect the system for patient mobility為方便病人活動而斷開系統
- DIncrease the flow rate if the urine becomes bright red如果尿液變為鮮紅色，增加流速
— Explanation · 中文詳解 —
CBI 系統為密閉引流，保持重力引流（低於膀胱）是防止逆流導致感染（Catheter-Associated Urinary Tract Infection, CAUTI）的最關鍵措施。監測尿液顏色（A）重要，但需先確保引流系統暢通。紅尿（D）應先評估血塊阻塞風險，而非直接加流速。斷開系統（C）絕對禁止。
The priority action is to ensure the drainage bag remains lower than the bladder to maintain gravity drainage and prevent backflow of urine. This positioning is critical for maintaining a closed system and reducing the risk of catheter-associated urinary tract infections. Disconnection of the system is prohibited, and flow rates should not be increased without assessing for clot obstruction.
✦ 台美臨床差異
美台對 CBI 的管理流程高度一致，皆強調密閉系統護理（Closed system management）。