— 降低風險 · MEDIUM · MCQ —
一位接受經尿道前列腺切除術（TURP）的病人正進行連續膀胱沖洗（CBI）。下列何種徵象需要護理師立即介入？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which finding requires immediate intervention?
- AThe client reports a feeling of fullness in the bladder✓ 正解病人主訴膀胱脹滿感
- BThe irrigation rate is 100 mL/hr沖洗速率為100 mL/hr
- CThe tubing has a small amount of sediment管路中有少量沉澱物
- DThe drainage is bright red with large clots引流液為鮮紅色並有大血塊
— Explanation · 中文詳解 —
膀胱飽脹感顯示導尿管可能因血塊阻塞，導致沖洗液無法排出。這會引起膀胱痙攣並導致尿液逆流，甚至造成傷口出血。鮮紅色血液在術後初期較常見，可調快沖洗速度；但導管阻塞必須立即處理以確保液流暢通，否則會危及術後傷口穩定。
Weight gain of 3 pounds in 2 days is a sensitive indicator of fluid retention and potential fluid overload in clients with heart failure. This rapid increase often precedes clinical signs like edema or pulmonary crackles, necessitating prompt evaluation and adjustment of diuretic therapy to prevent acute decompensation.
✦ 台美臨床差異
台灣泌尿科術後沖洗常由專科護理師或醫師評估決定流速，護理師需密切觀察排水。