護理師照護一位胸管引流病人。下列何種評估發現需要立即處理？
A nurse is caring for a client with a chest tube drainage system. Which assessment finding requires immediate intervention?
- AThe chest tube is securely taped to the skin胸管已牢固地貼附在皮膚上
- BContinuous bubbling in the water seal chamber✓ 正解水封瓶內有持續性氣泡
- CFluctuation of the fluid level in the water seal chamber水封瓶內液面隨呼吸波動
- DPresence of sanguineous drainage in the collection chamber收集瓶內有血性引流液
胸管水封瓶（Water seal）出現持續性氣泡（Continuous bubbling）代表胸腔內或管路系統存在漏氣，氣體不斷從大氣進入胸膜腔，可能導致張力性氣胸。間歇性氣泡在用力呼吸或咳嗽時出現是正常的。波動（Tidaling）代表呼吸壓力變化，是正常的引流現象。血性引流需依術後狀況判斷，非即刻致命徵象。
Continuous bubbling in the water-seal chamber of a chest tube indicates an air leak somewhere in the pleural cavity or tubing system, with air continuously entering the pleural space and potentially leading to tension pneumothorax. Intermittent bubbling that occurs with forceful breathing or coughing is normal. Tidaling reflects respiratory pressure changes and is a normal drainage finding. Sanguineous drainage must be assessed in the postoperative context but is not an immediately life-threatening finding.
美台對胸管系統的觀察指標一致，但美國護理師對胸管意外滑脫的即刻處置權限較大。