— 降低風險 · MEDIUM · MCQ —
護理師護理經尿道前列腺切除術（TURP）後進行持續膀胱沖洗（CBI）的病人，引流液變成鮮紅色並有大血塊。護理師應優先做什麼？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a TURP. The drainage becomes bright red with large clots. What is the nurse's priority action?
- ANotify the surgeon immediately立即通知外科醫師
- BAdminister a dose of IV aminocaproic acid給予一劑靜脈注射氨基己酸
- CRemove the catheter and re-insert a larger size拔除導尿管並重新插入較大尺寸
- DIncrease the rate of the irrigation solution✓ 正解增加沖洗溶液的流速
— Explanation · 中文詳解 —
經尿道前列腺切除術（TURP）後，持續膀胱沖洗（CBI）的主要目的是預防血塊堆積阻塞導尿管。若引流液呈現鮮紅色並伴隨大血塊，代表沖洗速度不足以排出血液凝塊。護理師的首要行動是「增加沖洗速度」，透過水壓將血塊沖出，維持引流管暢通，防止膀胱膨脹（Bladder distension）導致的劇烈疼痛與膀胱痙攣。若增加速度後仍未改善，才考慮進一步通知醫師。
Bright red drainage with large clots during continuous bladder irrigation (CBI) indicates that the current flow rate is insufficient to prevent catheter obstruction from blood accumulation. The nurse’s priority action is to increase the irrigation rate to flush out clots and maintain patency, preventing bladder distension and severe pain.