— 降低風險 · HARD · MCQ —
護理師照護一位接上密閉式胸腔引流系統的病人，下列哪項發現需要立即介入？
A nurse is caring for a client with a chest tube connected to a closed drainage system. Which of the following findings requires immediate intervention?
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BClient reports mild soreness at the insertion site病人報告插入處有輕微疼痛
- CFluctuation of the fluid in the water seal chamber水封瓶內液面隨呼吸波動
- DDrainage of 50 mL of serosanguineous fluid引流 50 mL 血清血性液體
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）代表氣管與胸腔間仍有大量空氣洩漏或系統漏氣，這是不正常的。正常狀況應只在咳嗽或深呼吸時出現間歇性氣泡（Intermittent bubbling）。此發現暗示氣胸未緩解或系統銜接處鬆脫，必須立即尋找漏氣點。
Continuous bubbling in the water seal chamber represents a significant air leak between the trachea and pleural space or in the system, and this is abnormal. Under normal conditions there should be only intermittent bubbling with coughing or deep breathing. This finding suggests unresolved pneumothorax or a loose connection in the system and requires immediate identification of the air leak.
✦ 台美臨床差異
兩地胸管護理均強調保持引流管路通暢、勿隨意夾管與確保系統密閉性。