一位接有胸腔引流管的患者在前往照 X 光途中，引流管意外與引流系統分離，護理師應優先採取什麼行動？
A client with a chest tube is being transported for an X-ray. The chest tube becomes accidentally disconnected from the drainage system. What is the nurse's priority action?
- AReconnect the tube to the system immediately立即將管子重新連接至引流系統
- BPlace the end of the tube into a bottle of sterile water✓ 正解將管子末端插入裝有無菌水的瓶子中
- CCover the site with a dry sterile dressing以乾燥無菌敷料覆蓋傷口
- DClamp the chest tube immediately立即夾住胸腔引流管
胸腔引流管脫落與系統分離時，首要目標是建立水封（Water Seal）系統以防止空氣進入胸膜腔導致張力性氣胸。將管子末端置入無菌水中可維持負壓同時讓空氣排出。D 錯誤，夾管會導致張力性氣胸。C 的動作需確保無菌，但建立水封是第一步。D 用於引流管完全拔出皮膚時。
When a chest drainage tube becomes disconnected from the system, the primary goal is to establish a water-seal system to prevent air from entering the pleural cavity and causing tension pneumothorax. Placing the end of the tube in sterile water maintains negative pressure while allowing air to escape. D is incorrect, because clamping the tube can lead to tension pneumothorax. The action in C requires maintaining sterility, but establishing a water seal is the first step. D applies when the chest tube has been pulled completely out of the skin.
台灣醫院標準作業程序（SOP）對胸管照護嚴謹，護理師普遍受過此緊急處置訓練，流程與國際一致。