— 降低風險 · MEDIUM · SATA —
護理師照護經尿道攝護腺切除術後接受持續膀胱沖洗（CBI）的病人，下列哪項觀察需立即介入？（選所有適合的）
A nurse is caring for a client with a continuous bladder irrigation (CBI) post-TURP. Which of the following observations require immediate intervention? (Select all that apply.)
- AUrine output is bright red with large clots✓ 正解尿液呈鮮紅色並有大血塊
- BThe client reports bladder spasms病人報告膀胱痙攣
- CThe catheter drainage tube shows no outflow✓ 正解導尿管引流管無尿液流出
- DThe irrigation fluid is light pink沖洗液呈淡粉紅色
- EThe client reports a feeling of fullness in the bladder✓ 正解病人報告膀胱脹滿感
— Explanation · 中文詳解 —
CBI 術後應觀察有無出血與阻塞。鮮紅色血塊（A）代表出血過多；無流出（C）與有膀胱充盈感（E）皆代表管路阻塞，極易導致膀胱破裂，需緊急沖洗或處理。淡粉色（D）為正常範圍，痙攣（B）為術後常見不適，非立即生命危險。
Bright red urine with large clots indicates active hemorrhage, while no outflow or a sensation of bladder fullness suggests catheter obstruction, both requiring immediate intervention to prevent complications like bladder rupture or significant blood loss.
✦ 台美臨床差異
美國常由護理師主導 CBI 速率，台灣有時需醫師調控速率，但緊急阻塞排除護理師皆需即刻處置。