— 降低風險 · MEDIUM · MCQ —
護理師照護一位放置胸管的術後病人，發現水封瓶持續冒泡。護理師應執行何項措施？
A nurse is caring for a postoperative client who has a chest tube. The nurse observes continuous bubbling in the water seal chamber. Which action should the nurse take?
- APosition the client on the affected side將病人置於患側
- BClamp the chest tube near the insertion site在插入部位附近夾閉胸管
- CCheck the entire tubing system for air leaks✓ 正解檢查整個管路系統是否有空氣洩漏
- DIncrease the suction pressure增加吸引壓力
— Explanation · 中文詳解 —
水封瓶持續冒泡通常意味著系統密閉性遭到破壞，空氣從外部進入管路。護理師應立即從病人端沿著管路檢查是否有鬆脫或破裂。臨床上，持續冒泡非正常現象，需優先排除氣漏問題以恢復負壓環境，而非調整吸引壓力或改變體位。
Continuous bubbling in the water seal chamber usually signals a break in system integrity, with air entering the tubing from outside. The nurse should immediately inspect the tubing from the patient end along the entire length for any loose connections or breaks. Clinically, persistent bubbling is abnormal, and the air leak must be resolved first to restore negative pressure, rather than adjusting suction pressure or repositioning the client.
✦ 台美臨床差異
美台臨床對於胸管護理標準相似，均嚴禁無醫囑夾閉管路。