護理師照護一位胸管引流病患，引流系統突然脫落，優先護理措施為何？
A nurse is caring for a client with a chest tube who experiences a sudden disconnection of the system. What is the priority nursing action?
- AReconnect the tubes immediately立即重新連接管路
- BClamp the chest tube to prevent air entry夾住胸管以防止空氣進入
- CApply a sterile occlusive dressing over the site在傷口處覆蓋無菌封閉性敷料
- DInsert the distal end of the chest tube into a bottle of sterile water✓ 正解將胸管的遠端插入裝有無菌水的瓶中
胸管脫落時，首要任務是建立水封閉（Water seal）以防止氣體進入胸腔造成氣胸。將管端插入滅菌蒸餾水或生理食鹽水中可建立水封閉，這是一個暫時性且安全的處置。直接 reconnect 若受污染會造成感染；夾住胸管有造成張力性氣胸的風險；封閉傷口是處理管路脫出體外的狀況，非管路斷裂。
If the chest tube system becomes disconnected, the priority is to establish a water seal to prevent air from entering the chest cavity and causing pneumothorax. Inserting the distal end of the tube into sterile distilled water or normal saline creates a temporary, safe water seal. Reconnecting without sterility risks contamination and infection; clamping the tube risks tension pneumothorax; and applying an occlusive dressing is for the situation where the tube is dislodged from the chest wall, not for a disconnected drainage system.
台美教學對於胸管意外處置一致，強調「保持水封閉」原則，並要求管路脫落時準備無菌水。