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TURP術後第0日病人具三向尿管並進行持續膀胱沖洗(CBI)中。哪些護理介入適當？請選擇所有適用項目。

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1 Assess for bladder distention, sudden severe spasms, or absent drainage — these may indicate clot obstruction requiring manual irrigation per protocol. 評估膀胱膨脹、突發劇烈痙攣或無引流 — 可能為血塊阻塞，依流程執行手動沖洗。 2 Calculate true urine output by SUBTRACTING the irrigation volume infused from the total drainage volume. 以總引流量減去注入沖洗量計算真實尿量。 3 Irrigate the catheter manually with 50 mL of sterile saline every 2 hours as a routine to maintain patency and prevent clot formation. 常規每2小時手動以50 mL無菌生理鹽水灌洗導管，以維持通暢及預防血塊形成。 4 Anticipate scheduled antimuscarinic agents (such as oxybutynin) or belladonna-and-opium suppositories for severe bladder spasms when ordered. 預期對嚴重膀胱痙攣，必要時將依醫囑使用抗膽鹼藥（如oxybutynin）或belladonna-and-opium栓劑。 5 Titrate the CBI rate to keep the urine output light pink to clear; increase the rate if output becomes darker red or contains clots. 調整CBI速率使尿色維持淡粉紅至清；變深紅或出現血塊時提高速率。

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