一位置入胸管的病人突然出現呼吸窘迫與低血壓，護理師應懷疑發生了什麼問題？
A client with a chest tube is suddenly experiencing respiratory distress and hypotension. What should the nurse suspect?
- ANormal tube drainage正常的胸管引流
- BPleural effusion胸膜積液
- CInfection at the site傷口感染
- DTension pneumothorax✓ 正解張力性氣胸
張力性氣胸（Tension pneumothorax）是胸腔科的致命急症。當胸膜腔內氣體持續累積且無法排出時，胸腔內壓力急劇上升，進而壓迫縱隔（Mediastinum）與大血管，導致靜脈回流受阻，引發低血壓與心輸出量下降。臨床表現包括呼吸窘迫、頸靜脈怒張、氣管偏離及患側呼吸音消失。護理師需優先懷疑此診斷，並立即通知醫師準備進行針頭減壓（Needle decompression）或胸管重新處置。
Tension pneumothorax is a life-threatening thoracic emergency. When air continues to accumulate in the pleural space and cannot escape, intrathoracic pressure rises rapidly, compressing the mediastinum and great vessels, impairing venous return and producing hypotension and decreased cardiac output. Clinical findings include respiratory distress, jugular venous distension, tracheal deviation, and absent breath sounds on the affected side. The nurse must suspect this diagnosis first and immediately notify the physician to prepare for needle decompression or reinsertion of a chest tube.
在美國臨床環境中，一旦懷疑張力性氣胸，護理師需立即執行緊急救護流程（如準備減壓器材），並強調在醫師到達前，護理師應評估胸管是否扭曲或阻塞，此為護理師職責範圍內的重要判斷。