一位胸管不慎脫落的病患，護理師的第一優先行動是什麼？
A nurse is caring for a client with a chest tube that has been accidentally removed. What is the nurse's immediate priority action?
- ACall the physician通知醫師
- BApply a sterile occlusive dressing secured on three sides✓ 正解貼上三面封閉的無菌封閉性敷料
- CInsert a new chest tube immediately立即插入新的胸腔引流管
- DCover the site with a dry sterile gauze以乾燥無菌紗布覆蓋傷口
胸管脫落會導致大氣直接進入胸膜腔，引發張力性氣胸，危及呼吸功能。正確的緊急處理方式是使用無菌封閉敷料（Occlusive dressing），並採取「三面封閉、一面開放」的原則。這樣的設計可以形成一個單向閥，在吸氣時敷料會吸附在傷口上防止空氣進入，在呼氣時則允許胸膜腔內多餘的空氣排出，從而防止張力性氣胸的形成。選擇 B 是不夠的，因為普通紗布無法防止空氣進入；C 是醫師的執行範圍；A 雖然要做，但必須先處理傷口防護，否則病人在等待醫師到來時可能已出現生命危險。這是標準的急救護理程序。
Dislodgement of a chest tube allows atmospheric air to enter the pleural cavity directly, causing tension pneumothorax and compromising respiratory function. The correct emergency response is to apply a sterile occlusive dressing secured on three sides with one side open. This design creates a one-way valve: during inspiration the dressing is drawn against the wound and prevents air entry, while during expiration excess air in the pleural cavity can escape, thereby preventing tension pneumothorax. Option D is insufficient because plain gauze cannot prevent air entry; option C is outside the nurse's scope of practice; option A is necessary but must come after wound protection - otherwise the client may deteriorate while waiting for the physician. This is the standard emergency nursing procedure.
美國護理教育極度強調「三面敷料」的操作細節，且常見於模擬考情境；台灣在臨床教學上亦強調此概念，但因現代急診多有即時手術覆蓋設備，實務上護理師操作頻率較少，教育強度略有差異。