護理師照護一位接受經尿道攝護腺切除術（TURP）後使用持續膀胱沖洗（CBI）的病人。觀察到尿液呈現鮮紅色並含有大量血塊。護理師應優先採取哪項措施？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The nurse notes the urine output is bright red with numerous large clots. Which action should the nurse take first?
- AManually irrigate the catheter with sterile normal saline以無菌生理食鹽水手動沖洗導尿管
- BNotify the healthcare provider immediately立即通知醫療提供者
- CAdminister prescribed analgesic for bladder spasms給予處方止痛藥以緩解膀胱痙攣
- DIncrease the rate of the continuous bladder irrigation✓ 正解增加持續膀胱沖洗（CBI）的速率
TURP 術後護理的核心目標是維持尿管通暢，防止血塊阻塞導致膀胱過度擴張與疼痛。當觀察到尿液變紅或有血塊時，首要動作是加快 CBI 的流速。加快流速能稀釋血液並沖走細小血塊，這是預防性與初步處理的首選。若加快流速後情況未改善或管路完全阻塞，才考慮手動沖洗（需醫囑或特定 protocol）或通知醫師。臨床安全原則要求護理師在發現異常時先進行獨立護理介入以緩解惡化，而非立即依賴他人。此處的鮮紅色與血塊是術後早期常見現象，但需透過流速管理來控制。
When bright red urine with large clots is observed during continuous bladder irrigation, the nurse should first increase the irrigation rate to help flush out clots and maintain catheter patency. This initial independent nursing action prevents obstruction and bladder distention before escalating to manual irrigation or notifying the provider if the problem persists.
美國 NCLEX 考試中，CBI 流速調整通常被視為護理師可根據尿液顏色自行決定的範疇（Standing order）；在台灣，部分醫院可能規定需在醫囑範圍內調整流速，但臨床實務上護理師多具備此初步處置權限。