# 一位個案留置了導尿管。哪項護理措施有助於降低導管相關感染風險？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397182&lang=zh-tw  
> language: zh-TW  
> subject: Mobility/Immobility  
> category: BCC

## 題目

一位個案留置了導尿管。哪項護理措施有助於降低導管相關感染風險？

## 選項

1. 每天分離引流管以排空殘留尿液。
2. 在運送過程中將引流袋抬高至膀胱水平以上。
3. 在沒有醫囑的情況下，每班常規沖洗導尿管。
4. 保持引流系統密閉，並將引流袋置於膀胱水平以下。 **✔ 正確答案**

**正確答案: 4**

## 解析

密閉的引流系統和將引流袋保持在膀胱水平以下，可減少污染和逆流。分離引流管和將引流袋抬高至膀胱以上會增加感染風險。沒有適應症和醫囑或標準程序，不進行常規沖洗。

## 深入解析

臨床判斷
利用個案線索、時機、檢驗數據和安全風險，選擇最符合留置導尿管照護的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶提取。

## 臨床情境

臨床實務指引
針對留置導尿管照護，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **留置導尿管** — 留置於膀胱內以持續引流尿液的管路。
- **密閉引流系統** — 保持密封以減少污染的導管系統。
- **逆流** — 尿液反向流動，可能將微生物帶向膀胱。

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