護理師照護的一位病人，胸管意外從胸壁被拉出（自插入部位脫出）。護理師應優先採取的行動為何？
A nurse is caring for a client whose chest tube has accidentally been pulled out of the chest wall (dislodged from the insertion site). What is the nurse's priority action?
- AAssess the client's vital signs評估個案的生命徵象
- BReinsert the chest tube重新插入胸管
- CApply a sterile dressing taped on three sides貼上三面固定的無菌敷料正確答案
- DCall the physician通知醫師
- C貼上三面固定的無菌敷料
胸管自胸壁意外脫出（accidentally dislodged from the chest wall）是急性醫療緊急情況，處理目標是防止空氣進入胸腔導致張力性氣胸（Tension pneumothorax）。使用三面封閉敷料（Three-sided occlusive dressing）是常見教學的急救措施（部分機構改用四面密封的無菌敷料並密切觀察呼吸狀況），形成單向閥：呼氣時空氣可排出，吸氣時敷料被吸附封住傷口，防止空氣進入，此處置必須立即執行，之後立即通知醫師評估是否需要重新置管。注意：這與「胸管從引流系統脫接（disconnected from the drainage system，但仍留在胸壁上）」是不同情境——後者應將管路末端浸入無菌水中重建水封，兩種情境都不可夾管。
- A評估個案的生命徵象
評估生命徵象應在完成急救處置後進行，目前首要目標是封閉傷口。
- B重新插入胸管
重新插入胸管必須由醫師在無菌環境下進行，護理師不可自行操作。
- C · 正確答案貼上三面固定的無菌敷料
三面封閉敷料能形成單向閥，是胸管脫落時防止空氣進入胸腔的標準急救處置。
- D通知醫師
通知醫師是必要的，但必須先執行急救處置以維持胸腔負壓，防止氣胸惡化。
美國臨床對於胸管脫落的處理極為明確，三面封閉敷料（Three-sided dressing）是 NCLEX 指定的標準處置。若為胸管從排水瓶脫落，則應將管路置入無菌水中以維持水封（Water seal），這也是護理師必備的急救知識。
English explanation
Option C is correct because immediate application of a sterile dressing taped on three sides is the commonly taught first-aid measure (some facilities use a fully sealed sterile occlusive dressing with close respiratory monitoring) intended to prevent air from entering the pleural space after a chest tube is pulled from the chest wall. The dressing functions as a one-way valve: air can leave during exhalation, while inhalation draws the dressing against the wound and blocks air entry, reducing the risk of tension pneumothorax. This action comes first, followed immediately by notifying the physician to assess whether a new tube is needed, so Option D is not the initial priority. This event differs from disconnection of the tube from the drainage system while the tube remains in the chest wall. For that situation, the tube end is placed in sterile water to restore a water seal. The tube must not be clamped in either situation.
最近修訂：2026-09-30