— 降低風險 · MEDIUM · SATA —
護理師照護一位經尿道前列腺切除術後，進行連續膀胱沖洗（CBI）的病人。下列哪些發現需立即介入？（選所有適合的）
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a TURP. Which findings require immediate intervention? (Select all that apply.)
- APresence of bright red blood in the drainage✓ 正解引流管中有鮮紅色血液
- BClient reports bladder spasms病人報告膀胱痙攣
- CDrainage output is less than the irrigation input✓ 正解引流量少於沖洗液輸入量
- DSmall blood clots noted in the bag引流袋中發現少量血塊
- EAbsence of output despite irrigation flow✓ 正解儘管有沖洗液流入卻無引流輸出
— Explanation · 中文詳解 —
CBI 術後應維持引流液呈淡粉紅色。若出現鮮紅色出血（出血過多）、引流量少於沖洗量（尿管堵塞），或完全沒有輸出（嚴重閉塞），皆代表膀胱或導管出現問題。膀胱痙攣（B）為常見術後症狀，通常給予解痙劑即可；小血塊（D）若量少可容忍。
To ensure safety for a client with a latex allergy, the nurse should use non-latex, powder-free gloves, select non-latex medical equipment such as tubing and tourniquets, and flag the client's chart to alert the healthcare team. Placing the client in a room with latex-containing supplies or using tapes with rubber adhesives poses a significant risk of allergic reaction.
✦ 台美臨床差異
美國護理師常依據醫囑執行手動沖洗（manual irrigation），台灣護理師亦同，皆需密切監測引流顏色。