— 基本照護與舒適 · MEDIUM · MCQ —
對於尿瀦留的病人，下列哪項護理措施最合適？
Which of the following nursing interventions is most appropriate for a client with urinary retention?
- AInserting an indwelling urinary catheter immediately立即插入留置導尿管。
- BApplying a cold compress to the suprapubic area在恥骨上區域應用冷敷。
- CEncouraging a high fluid intake immediately立即鼓勵大量攝取流質。
- DProviding privacy and using sensory stimuli like running water✓ 正解提供隱私，並使用如流水聲等感官刺激。
— Explanation · 中文詳解 —
處理尿瀦留（Urinary retention）應遵循「由非侵入性到侵入性」的護理原則。提供隱私、調整姿勢（如採坐姿）或利用流水聲暗示，能有效刺激排尿反射。若非必要，應儘量避免立即導尿，因為導尿屬於侵入性行為，會顯著增加泌尿道感染風險。冷敷 suprapubic area 會刺激交感神經，反而導致括約肌緊縮，不利於排尿。
Non-invasive interventions, such as providing privacy and using sensory stimuli like running water, are the first-line approach to encourage voiding by relaxing the urethral sphincter. These methods align with the principle of least restriction before considering invasive options like catheterization, which carry higher infection risks.