— 照護管理 · HARD · MCQ —
護理師照護多位病人，下列哪項發現需要護理師立即進行介入處理？
A nurse is caring for multiple clients. Which of the following findings requires the nurse to intervene immediately?
- AA client reporting 4/10 pain level after receiving oral analgesics.一位在接受口服止痛藥後報告疼痛程度為 4/10 的病人。
- BA client with a chest tube showing continuous bubbling in the water seal chamber.✓ 正解一位胸腔引流管的水封瓶中有持續冒泡現象的病人。
- CA client with an IV infusion running at 150 mL/hr instead of the prescribed 100 mL/hr.一位靜脈輸注速率為 150 mL/hr，而非處方的 100 mL/hr 的病人。
- DA client with a urinary catheter having 30 mL of output in the past 2 hours.一位過去 2 小時內導尿管尿量為 30 mL 的病人。
— Explanation · 中文詳解 —
胸管水封瓶持續冒泡（continuous bubbling）通常代表系統出現空氣滲漏（air leak），這是需要優先處理的緊急狀況。其他選項如 30 mL/2 hr 尿量雖需追蹤但非絕對緊急；點滴過快需調整但非立即威脅生命；疼痛緩解為預期狀況。
Continuous bubbling in the water-seal chamber of a chest tube system usually indicates an air leak in the system, which is an emergency requiring priority intervention. The other options, such as urine output of 30 mL over 2 hours, require monitoring but are not absolutely emergent; an IV infusing too fast must be adjusted but is not an immediate life threat; pain relief is an expected outcome.
✦ 台美臨床差異
美台臨床對於胸管護理的處置程序高度相似，均強調發現空氣滲漏需立即檢修，防止張力性氣胸發生。