一位接受肺葉切除術並置入胸管的病人，在過去一小時內引流瓶中出現了 100 mL 的鮮紅色引流液。病人心率為 105 次/分，血壓為 108/64 mmHg。護理師應採取哪項行動？
A client with a chest tube following a lobectomy has 100 mL of bright red drainage in the collection chamber over the last hour. The client's heart rate is 105 beats/min and blood pressure is 108/64 mmHg. Which action should the nurse take?
- APosition the client on the affected side將病人置於患側
- BDocument the findings and continue to monitor記錄發現並繼續監測
- CMilk the chest tube to ensure patency擠壓胸管以確保暢通
- DNotify the healthcare provider immediately✓ 正解立即通知醫療提供者
胸管護理的重點在於觀察引流量的性質與量。對於成人而言，每小時引流量大於 100 mL（有些指引為 70-100 mL）且呈現鮮紅色（Active bleeding），被視為異常且需立即處理。此外，病人的生命徵象顯示輕微心搏過速與血壓偏低，這可能是出血導致低血容的早期跡象。護理師必須立即通知醫師（D）。選項 C（擠壓管路/Milking）在現代護理中是不被推薦的，因為會造成胸腔內負壓驟增，可能損傷組織；選項 B（僅紀錄監測）會延誤治療；選項 A 雖然可促進引流，但無法解決出血問題且可能增加病人不適。及時回報是護理師在面對術後出血危象時的專業職責。
The focus of chest tube care is observing the nature and amount of drainage. For adults, drainage greater than 100 mL/hr (some guidelines use 70-100 mL/hr) that is bright red (active bleeding) is considered abnormal and requires immediate action. In addition, the client's vital signs show mild tachycardia and low-normal blood pressure, which may be early signs of bleeding-induced hypovolemia. The nurse must notify the physician immediately (D). Option C (milking the chest tube) is no longer recommended in modern nursing, because it causes a sudden surge in intrathoracic negative pressure and may damage tissue; option B (documenting and continuing to monitor) would delay treatment; option A may promote drainage but does not address the bleeding and may increase discomfort. Timely reporting is the nurse's professional responsibility in the face of postoperative bleeding crises.
在美國，100 mL/hr 是一個公認的『呼叫醫師』紅線值。在台灣，有些臨床單位可能設定更嚴格（如連續兩小時 >100 或單次 >200），但為了應考 NCLEX，100 mL 是必須記住的關鍵門檻。