護理師照護一位置入胸管的病人。下列哪項發現應立即告知醫師？
A nurse is caring for a client with a chest tube. Which finding should be immediately reported to the healthcare provider?
- AThe chest tube dressing is dry and intact胸管敷料乾燥且完整
- B100 mL of serosanguinous drainage in the collection chamber收集腔內有 100 mL 血清血性引流液
- CContinuous bubbling in the water seal chamber✓ 正解水封腔內持續冒泡
- DTidaling observed in the water seal chamber水封腔內觀察到潮汐現象
胸管水封瓶（Water seal chamber）持續性冒泡通常代表胸膜腔存在空氣洩漏（Air leak）。若冒泡持續且無法排除來源，代表病人的肺部可能存在持續性的氣胸，或是胸管系統破裂，這會影響肺部擴張，需緊急排除異常。Tidaling 是正常的呼吸動作反映；100mL 流量屬可接受範圍；敷料完整是良好照護的表現。
Continuous bubbling in the chest tube water-seal chamber usually indicates an air leak in the pleural space. If the bubbling continues and the source cannot be ruled out, it suggests possible persistent pneumothorax or rupture of the chest tube system, which affects lung expansion and requires urgent intervention. Tidaling reflects normal respiratory motion; 100 mL of drainage is within an acceptable range; and an intact dressing represents good care.
美國護理師常依據醫院護理指導方針自行排查漏氣源頭，台灣護理師多需醫師確認後再做管路處置。