— 生理適應 · MEDIUM · SATA —
護理師照護胸管病人，下列哪些發現顯示可能有併發症？（選所有適合的）
A nurse is caring for a client with a chest tube. Which findings indicate the client is experiencing a potential complication? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BSubcutaneous emphysema around the insertion site✓ 正解插管處周圍出現皮下氣腫
- CFluctuation of the fluid level in the water seal chamber水封瓶內液面隨呼吸波動
- DClient reports sudden sharp chest pain✓ 正解病人主訴突發性銳利胸痛
- EDrainage output of 50 mL in the last hour最後一小時引流液為 50 mL
— Explanation · 中文詳解 —
胸管（Chest Tube）的照護重點在於維持胸腔負壓與監測引流狀況。持續性氣泡（Continuous bubbling）暗示系統漏氣（Air leak）；皮下氣腫（Subcutaneous emphysema）顯示空氣逸散至皮下；突發胸痛則需懷疑氣胸惡化或管路阻塞。這些皆為異常發現，需立即處理以防張力性氣胸等致命併發症。
Care of a chest tube focuses on maintaining negative intrathoracic pressure and monitoring drainage. Continuous bubbling indicates an air leak in the system; subcutaneous emphysema indicates air escaping into subcutaneous tissue; sudden chest pain raises concern for worsening pneumothorax or tube obstruction. All are abnormal findings requiring immediate action to prevent life-threatening complications such as tension pneumothorax.