— 照護管理 · HARD · MCQ —
在照護連續膀胱灌洗（CBI）的病人時，哪項發現需要護理師立即介入？
Which assessment finding requires the nurse to intervene immediately during the care of a client with a continuous bladder irrigation (CBI)?
- ADrainage is bright red with large clots✓ 正解引流液呈鮮紅色並有大血塊
- BClient reports a feeling of bladder fullness病人報告有膀胱脹滿感
- CDrainage is pink-tinged引流液呈現淡粉紅色
- DThe irrigation fluid is dripping steadily灌洗液持續穩定滴注
— Explanation · 中文詳解 —
連續膀胱灌洗（CBI）術後引流液應為粉紅色（Pink-tinged），代表微量出血。若引流液呈現鮮紅色（Bright red）且含有大量血塊（Large clots），代表有活動性出血或管路阻塞。這會導致膀胱內壓升高，造成病人劇烈疼痛及膀胱膨脹，嚴重時甚至會導致敗血症或急性腎衰竭。護理師必須立即介入，檢查管路是否有扭曲、進行手動沖洗以移除血塊，並通知醫師。
Bright red drainage with large clots during continuous bladder irrigation suggests active hemorrhage or catheter obstruction, requiring immediate intervention. Unlike pink-tinged drainage, which is expected post-operatively, significant clotting can increase bladder pressure and cause complications such as rupture or infection.