護理師照護的一位病人胸管脫落，護理師優先採取的行動為何？
A nurse is caring for a client with a chest tube that has been disconnected. What is the nurse's priority action?
- AAssess the client's vital signs評估客戶的生命徵象
- BReinsert the chest tube重新插入胸管
- CApply a sterile dressing taped on three sides✓ 正解貼上三面固定的無菌敷料
- DCall the physician通知醫師
胸管脫落（Chest tube disconnection）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 dressing）是標準急救措施，它形成單向閥，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。
A disconnected chest tube is an acute medical emergency, and the goal of management is to prevent air from entering the pleural cavity and causing a tension pneumothorax. Applying a sterile dressing taped on three sides is the standard emergency measure: it acts as a one-way valve, allowing air to escape on exhalation while sealing on inhalation to prevent further air entry. This intervention must be performed immediately.
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。