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生理適應 · MEDIUM · MCQ

為維持胸管引流系統的完整性,哪項護理措施是適當的?

Which intervention is appropriate for a client with a chest tube to maintain system integrity?

  • AKeep the drainage system below the level of the chest✓ 正解
    保持引流系統低於胸腔水平
  • BClamp the chest tube to prevent air leaks
    夾住胸管以防止漏氣
  • CPlace the drainage container on the bed
    將引流容器放置在床上
  • DStrip the chest tube every 2 hours
    每 2 小時擠壓胸管
Explanation · 中文詳解

胸管引流系統(Chest Tube Drainage System)是利用水封瓶(Water Seal)原理,透過重力與負壓協助肺部擴張並排除胸腔積液或氣體。引流瓶必須始終保持在病人胸腔水平以下,以防止引流液因重力作用逆流回胸腔造成感染或壓迫肺組織。護理師需確保管路通暢且無扭曲,同時注意水封瓶內是否有波動(Tidaling),這是肺部擴張功能的指標。

A chest tube drainage system uses the water-seal principle and relies on gravity and negative pressure to help the lung expand and drain fluid or air from the pleural cavity. The drainage chamber must always be kept below the level of the patient's chest to prevent reflux of drainage fluid back into the pleural cavity, which could cause infection or lung compression. The nurse must ensure that the tubing is patent and free of kinks and observe for tidaling in the water-seal chamber, which is an indicator of lung-expansion function.

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