— 降低風險 · HARD · SATA —
護理師照護一位放置胸管的病人。下列哪些觀察指標顯示系統運作正常？（選所有適合的）
A nurse is caring for a client who has a chest tube. Which findings indicate the system is functioning correctly? (Select all that apply.)
- AContinuous bubbling in the water seal chamber水封室持續冒泡
- BFluctuation in the water seal chamber with respiration✓ 正解水封室隨呼吸起伏
- CBubbling in the suction control chamber✓ 正解吸引控制室冒泡
- DDependent loops in the drainage tubing引流管路有下垂環
- EDrainage in the collection chamber✓ 正解收集室有引流液
— Explanation · 中文詳解 —
胸管水封瓶應隨呼吸波動（潮動），若無波動可能表示管路阻塞。吸引控制瓶（Suction control chamber）出現冒泡表示吸引功能運作中。若在水封室（Water seal chamber）出現持續冒泡，則代表系統有漏氣。管路不可有垂懸積液（Dependent loops），以免增加呼吸阻力。
The water seal chamber of a chest tube system should fluctuate (tidal) with respiration; absence of fluctuation may indicate that the tubing is obstructed. Bubbling in the suction control chamber indicates that suction is working. Continuous bubbling in the water seal chamber indicates that the system has an air leak. Tubing must not contain dependent loops, as these increase respiratory resistance.
✦ 台美臨床差異
在美國臨床，護理師需負責確認 suction 壓力設定，而台灣護理師通常由醫師設定後由護理師監測。