— 降低風險 · HARD · MCQ —
針對使用胸管的病人，下列哪個評估發現應優先處理？
Which assessment finding in a client with a chest tube should the nurse prioritize?
- A100 mL of serosanguineous drainage in 8 hours8 小時內有 100 mL 血清血性引流液
- BSubcutaneous emphysema near the insertion site插管處附近的皮下氣腫
- CFluctuation in the water seal chamber with respirations水封瓶內隨呼吸而波動
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）通常代表系統存在漏氣（Air leak），若排除管路連接問題，則極可能源自病人胸腔持續漏氣，這可能導致張力性氣胸，是緊急狀況。相比之下，波動（Tidaling）是正常呼吸動作；皮下氣腫需監測但非立即危急；適量引流量屬預期結果。
Continuous bubbling in the water seal chamber generally indicates an air leak; if tubing connection issues are excluded, it most likely reflects persistent air leakage from the client's chest, which can lead to tension pneumothorax and is an emergency. In comparison, tidaling is a normal respiratory phenomenon; subcutaneous emphysema requires monitoring but is not immediately life-threatening; and moderate drainage is an expected finding.
✦ 台美臨床差異
美台護理臨床對於胸管護理標準一致，重點均在於預防感染與維持封閉系統，但在排查漏氣來源時，台灣多會立即請醫師評估。