護理師評估一位裝有胸管及水封式引流系統的病人。哪項發現顯示有潛在問題需要介入？
A nurse is assessing a client with a chest tube connected to a water-seal drainage system. Which finding indicates a potential problem that requires intervention?
- AOccasional bubbling in the water-seal chamber during coughing咳嗽時水封瓶內偶爾出現氣泡
- B200 mL of serosanguineous fluid in the collection chamber over 24 hours收集瓶內 24 小時有 200 mL 的血清血性液體
- CContinuous bubbling in the water-seal chamber✓ 正解水封瓶內持續出現氣泡
- DFluctuation of the water level with respiration水位隨呼吸波動
在水封式引流系統中，水封腔（Water-seal chamber）的「持續」氣泡（Continuous bubbling）通常代表系統存在漏氣（Air leak），這可能發生在胸管插入處、引流管接頭或病人胸腔內。正常的狀況是水柱隨呼吸起伏（Tidaling），且只有在咳嗽、用力呼氣或初始排氣時會有「間歇性」氣泡。24 小時引流 200 mL 淡血水屬於正常範疇（通常每小時 >100 mL 才需警覺）。護理師必須能區分正常起伏與異常漏氣，並具備初步排查漏氣點的能力（如短暫夾管檢查）。這對於維持胸腔負壓、防止肺塌陷惡化至關重要，是減少術後風險的核心職責。
In a water-seal drainage system, continuous bubbling in the water-seal chamber usually indicates an air leak in the system, which can occur at the chest tube insertion site, at a tubing connection, or within the client's chest cavity. The normal finding is tidaling (fluctuation of the water column with respirations), with intermittent bubbling only during coughing, forceful exhalation, or initial air evacuation. A 24-hour output of 200 mL of serosanguineous drainage is within the expected range (typically more than 100 mL/hr would warrant concern). The nurse must be able to differentiate normal tidaling from an abnormal air leak and to perform initial troubleshooting (such as a brief clamping test). This is essential to maintain negative intrapleural pressure and prevent worsening lung collapse, and is a core responsibility for reducing postoperative risk.
美國 NCLEX 考題經常測試漏氣位置的判斷（夾管法）；台灣臨床上，護理師發現持續氣泡後，除了檢查接頭外，通常會迅速通報醫師或胸腔外科，並備妥無菌敷料以防萬一。