— 降低風險 · HARD · MCQ —
護理師照護一位裝有胸管的病人。發現水封瓶持續冒泡，護理師應採取什麼行動？
A nurse is caring for a client with a chest tube. The nurse observes continuous bubbling in the water seal chamber. Which action should the nurse take?
- AAssess the tubing connection for an air leak✓ 正解檢查管路連接處是否有漏氣
- BIncrease the suction pressure增加抽吸壓力
- CClamping the chest tube near the insertion site在插入部位附近夾住胸管
- DImmediately remove the chest tube立即拔除胸管
— Explanation · 中文詳解 —
水封瓶持續冒泡（continuous bubbling）通常代表系統出現氣漏（air leak）。首先應順著胸管路徑檢查連接處是否鬆脫，若排除連接處問題，則可能是病人肺部氣漏持續。切勿直接夾管，因為這可能導致氣胸惡化為張力性氣胸。
Continuous bubbling in the water seal chamber usually indicates an air leak in the system. The nurse should first trace the chest tube system to check whether the connections are loose; if connections are not the issue, ongoing pulmonary air leakage from the client may be present. The chest tube should never be clamped directly, because this can convert a simple pneumothorax into a life-threatening tension pneumothorax.
✦ 台美臨床差異
美國護理師常須具備故障排除能力，台灣臨床較習慣先通報醫師協助檢查，但評估技巧皆相同。