護理師評估一位放置胸管的病人。下列哪項發現應立即報告醫師？
A nurse is assessing a client with a chest tube. Which finding should the nurse report to the physician immediately?
- A100 mL of dark red drainage in the last hour✓ 正解過去一小時內引出 100 mL 暗紅色引流液
- BStable respiratory rate呼吸速率穩定
- CGentle bubbling in the water seal chamber水封瓶內有輕微冒泡
- DFluctuation of fluid in the water seal chamber水封瓶內液面波動
胸管引流（chest tube drainage）的目的是移除胸腔內的空氣、血液或積液，幫助肺部復張。護理師需要密切監測引流量、胸腔引流系統的運作情況，並及時發現異常。 選項 A 是應立即報告的警訊。若在過去一小時內引流出 100 毫升（100 mL）的深紅色液體，這表示胸腔內可能存在活動性出血（active bleeding）。特別是如果這是術後早期，大量出血可能需要緊急手術處理。雖然引流量的判斷標準會因病人情況（如術後時間、出血原因）而異，但一小時內 100mL 的深紅色血液通常被視為需要立即評估的異常狀況。 選項 C（水中封閉室的輕微冒泡，gentle bubbling in the water seal chamber）是正常的現象，表示空氣正在從胸腔排出，這是胸管運作良好的跡象。 選項 B（呼吸速率穩定）表示病人的呼吸功能目前是穩定的，不屬於緊急狀況。 選項 D（水中封閉室的液體波動）是正常的現象。當病人呼吸時，水封室內的液面應隨呼吸起伏（fluctuation），這表示胸管與肺部之間有通暢的通道，且沒有完全阻塞。 臨床思路（Priority / Assessment / Safety）：對於胸管病人，監測引流量是評估出血情況和肺部復張的重要指標。大量或突然增加的引流量是潛在出血的警訊，需立即處理。
The purpose of chest tube drainage is to remove air, blood, or fluid from the pleural space, allowing the lung to re-expand. The nurse must monitor drainage output and the function of the drainage system closely in order to detect abnormalities promptly. Option A is a warning sign that must be reported immediately. Drainage of 100 mL of dark red fluid within the last hour suggests active intrathoracic bleeding. Particularly in the early postoperative period, significant bleeding may require emergency surgical intervention. Although the threshold for concern varies with the clinical scenario (such as time since surgery and source of bleeding), 100 mL of dark red drainage within one hour is generally considered an abnormal finding requiring immediate evaluation. Option C (gentle bubbling in the water seal chamber) is a normal finding indicating that air is being evacuated from the pleural space, a sign of proper chest tube function. Option B (a stable respiratory rate) indicates that the client's respiratory function is currently stable and does not represent an emergency. Option D (fluctuation of fluid in the water seal chamber) is a normal finding. With each respiratory cycle, the fluid level in the water seal chamber should rise and fall (tidaling), indicating a patent connection between the chest tube and the lung without complete obstruction. Clinical reasoning (Priority / Assessment / Safety): for clients with a chest tube, monitoring drainage output is a key indicator of bleeding and lung re-expansion. A large or sudden increase in drainage volume is a warning sign of potential hemorrhage and requires immediate action.