— 生理適應 · EASY · MCQ —
一位胸管留置的病人，出現下列哪種臨床徵象時，護理師應立即通知醫師？
Which of the following clinical findings in a client with a chest tube should the nurse report to the healthcare provider immediately?
- AFluctuation of the fluid in the water seal tube水封管內液面波動
- BIntermittent bubbling in the water seal chamber水封腔內間歇性冒泡
- CConstant, vigorous bubbling in the suction control chamber抽吸控制腔內持續劇烈冒泡
- D200 mL of bright red blood drainage within one hour✓ 正解一小時內引流 200 mL 鮮紅色血液
— Explanation · 中文詳解 —
胸管（Chest tube）護理的關鍵在於監測引流系統的完整性與病人的血流動力學狀態。短時間內出現大量鮮紅色引流液（通常定義為一小時超過 100-200 mL）代表存在活動性出血（Active hemorrhage），這是危及生命的緊急狀況，可能引發出血性休克。此時必須立即通知醫療團隊，並準備相關急救措施。
Draining 200 mL of bright red blood within one hour indicates active, massive hemorrhage, which is a life-threatening emergency that requires immediate medical intervention. While fluctuations and intermittent bubbling are normal findings, constant vigorous bubbling in the suction chamber is also expected, making the volume and color of drainage the critical indicator of complications.