— 生理適應 · MEDIUM · MCQ —
護理師照護一位接有水封式胸腔引流系統的病患，觀察到水封瓶出現持續性氣泡。首要行動為何？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. What is the priority action?
- ACheck for air leaks at the insertion site and connections✓ 正解檢查插入口及連接處是否有漏氣
- BClamp the chest tube immediately立即夾住胸管
- CIncrease the suction pressure增加吸引壓力
- DNotify the physician通知醫師
— Explanation · 中文詳解 —
水封式胸腔引流系統（Water-seal drainage）的水封瓶出現持續性氣泡，通常代表系統有「空氣洩漏（Air leak）」。護理師應優先檢查管路連接處是否鬆脫、管路有無裂痕或敷料覆蓋是否緊密。嚴禁隨意夾住胸管，以免氣體無法排出引發致命的張力性氣胸（Tension pneumothorax）。
Continuous bubbling in the water-seal chamber of a water-seal drainage system typically indicates an air leak in the system. The nurse should first check whether tubing connections are loose, whether the tubing has cracks, and whether the dressing is securely applied. Never clamp the chest tube indiscriminately, as this prevents air from escaping and may cause a fatal tension pneumothorax.