— 降低風險 · MEDIUM · MCQ —
護理師協助一位經尿道前列腺切除術（TURP）後執行連續膀胱沖洗（CBI）的病人。下列哪項觀察需立即介入？
A nurse is assisting a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which observation requires immediate intervention?
- AOutput less than the total irrigation input✓ 正解引流量少於總灌洗輸入量
- BClient reporting a need to void病人主訴有排尿感
- CSmall blood clots in the drainage tubing引流管中有少量血塊
- DLight pink drainage in the catheter bag導尿袋中引流液呈淡粉紅色
— Explanation · 中文詳解 —
連續膀胱沖洗（CBI）主要用於預防經尿道前列腺切除術後產生血塊阻塞。正常情況下，沖洗液會持續流入並帶出血液，引流量應大於或等於輸入量。若引流量顯著少於輸入量，代表引流管可能被血塊阻塞或管路扭曲，導致沖洗液滯留於膀胱內。此時膀胱會過度膨脹，引發劇烈疼痛，嚴重者可能導致膀胱破裂或繼發性出血，故必須視為緊急情況立即處理。
Output less than the total irrigation input indicates potential obstruction from blood clots or tubing kinking, which can lead to bladder distension and rupture. This requires immediate intervention to restore patency and prevent serious complications.