下列何種評估結果顯示胸管引流病人可能發生張力性氣胸？（選所有適合的）
Which assessment findings indicate that a client with a chest tube is experiencing a tension pneumothorax? (Select all that apply.)
- ATracheal deviation toward the unaffected side✓ 正解氣管向未受影響側偏移
- BHypotension and tachycardia✓ 正解低血壓與心搏過速
- CAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- DIncreased chest tube output of bright red blood胸管引流量增加且為鮮紅色血液
- EDistended neck veins✓ 正解頸靜脈怒張
張力性氣胸是致命性併發症，空氣進入胸膜腔且無法排出，導致胸內壓急劇上升。壓迫縱膈腔導致氣管偏移（健側）、影響靜脈回流引發低血壓與頸靜脈怒張、以及患側呼吸音消失。血性引流增加通常指向出血，而非張力性氣胸的典型特徵。
Tension pneumothorax is a life-threatening complication in which air enters the pleural space and cannot escape, causing a rapid rise in intrathoracic pressure. The pressure compresses the mediastinum, shifting the trachea to the unaffected side, impairing venous return (causing hypotension and jugular venous distention), and producing absent breath sounds on the affected side. Increased bloody drainage usually points to hemorrhage rather than being a typical feature of tension pneumothorax.
美國護理師常需負責張力性氣胸的緊急處置如針頭減壓（依州執業範圍），台灣則多由醫師執行。