— 降低風險 · MEDIUM · MCQ —
護理師照護一位經尿道前列腺切除術（TURP）後進行連續膀胱沖洗（CBI）的病人，應採取下列哪項措施？
Which of the following actions should the nurse take when caring for a client with a continuous bladder irrigation (CBI) following a TURP?
- AStop the irrigation if the client reports bladder spasms若病人主訴膀胱痙攣，則停止沖洗
- BEmpty the drainage bag only once per shift每班次僅排空引流袋一次
- CIncrease irrigation rate if the output is bright red with large clots若引流液呈鮮紅色且含有大量血塊，則增加沖洗速率
- DMaintain output to ensure it remains clear or light pink✓ 正解維持引流液清澈或呈淡粉紅色
— Explanation · 中文詳解 —
經尿道前列腺切除術（TURP）後進行連續膀胱沖洗（CBI）的主要目的是防止血塊堆積阻塞尿管。護理重點在於監測引流液顏色，理想狀態應維持淡粉紅色（Light pink），若引流液變為鮮紅色或出現大量血塊，表示有活動性出血，需增加沖洗速度以利血塊排出，避免阻塞造成膀胱痙攣（Bladder spasms）。
The primary goal of continuous bladder irrigation (CBI) after a transurethral resection of the prostate (TURP) is to prevent clot formation and urinary obstruction. The nurse should aim to maintain the drainage output as clear or light pink; if the fluid becomes bright red with clots, the irrigation rate may need adjustment to flush out blood and prevent blockage.