# 一位執行腹膜透析的個案主訴新發生的腹痛，且引流出的透析液混濁。護理師應提供哪一項指導？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=498093&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

一位執行腹膜透析的個案主訴新發生的腹痛，且引流出的透析液混濁。護理師應提供哪一項指導？

## 選項

1. 增加下一袋透析液的葡萄糖濃度以移除更多液體
2. 在繼續治療前，用微波爐加熱下一袋透析液
3. 繼續常規換液，明天再檢查引流液
4. 立即通知透析團隊，並保留引流袋以供評估 **✔ 正確答案**

**正確答案: 4**

## 解析

腹痛合併混濁的腹膜透析流出液，暗示腹膜炎，這是一種需要立即評估與治療的嚴重感染。個案應立即通知透析團隊，並保留引流袋，以便根據治療計畫評估流出液。

## 深入解析

快速解答
立即報告混濁流出液與腹痛。這些是腹膜透析相關腹膜炎的警訊。

為什麼這是正確的
腹膜透析使用留置導管，可能將細菌引入腹腔。發炎反應使流出液充滿細胞與碎片而變得混濁，腹痛則反映腹膜刺激；延遲治療可能導致敗血症或導管喪失。

簡單比喻或心智圖像
正常清澈的透析液就像一扇乾淨的窗戶，可觀察換液過程。新出現的混濁是警報，表示有東西在裡面聚集，但外觀無法辨識病原體，仍需實驗室評估。

記憶掛鉤
混濁流出液加上腹痛，就要懷疑腹膜炎，立即通知透析團隊。

NCLEX 決策規則
針對腹膜透析，將混濁的用過透析液、腹痛、發燒或導管出口感染徵象視為緊急情況。保留有用的證據，並立即尋求透析團隊的指導，而非自行調整處方。

為什麼其他選項是錯的
改變透析液葡萄糖濃度無法治療感染。用微波爐加熱透析液可能產生危險的熱點，且無法治療感染。等到明天才處理，會延誤對這項嚴重透析併發症的照護。立即通報並保留引流袋，有助於快速評估。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]NIDDK: Peritoneal DialysisNational Institute of Diabetes and Digestive and Kidney Diseases

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