— 降低風險 · HARD · MCQ —
護理師照顧一位經尿道前列腺切除術後進行膀胱連續沖洗的病人，引流袋尿液呈鮮紅色且有許多血塊。護理師應先執行什麼？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a TURP. The urine in the drainage bag is bright red with numerous clots. What should the nurse do first?
- ANotify the surgeon immediately立即通知外科醫師
- BAdminister an ordered analgesic給予處方止痛藥
- CIncrease the CBI flow rate✓ 正解增加連續膀胱沖洗 (CBI) 的流速
- DDeflate the catheter balloon放氣導尿管氣囊
— Explanation · 中文詳解 —
經尿道前列腺切除術（TURP）術後進行膀胱連續沖洗（CBI），目的是防止血塊堆積阻塞導管，引發膀胱痙攣。當引流液呈鮮紅色且有血塊時，代表出血量大或引流不暢。首要介入是增加沖洗速度（Increase flow rate），以物理方式沖刷血塊，確保管路暢通。若沖洗速度增加後引流仍不佳，才考慮通知醫師，因為引流受阻會導致膀胱過度膨脹，引發劇烈疼痛與出血。
Bright red urine with clots indicates active bleeding and potential catheter obstruction, which requires immediate intervention to maintain patency. The nurse should first increase the continuous bladder irrigation (CBI) flow rate to flush out clots and prevent bladder distention and spasms.