病人的胸管引流系統在水封瓶中出現持續性氣泡。護理師首要採取的行動為何？
A client with a chest tube drainage system has continuous bubbling in the water seal chamber. What is the most appropriate initial nursing action?
- AClamp the chest tube close to the insertion site在靠近插入處夾住胸管
- BIncrease the suction pressure增加抽吸壓力
- CCheck the entire tubing system for loose connections✓ 正解檢查整個管路系統是否有鬆脫的連接處
- DReplace the entire drainage system更換整個引流系統
水封瓶持續氣泡代表系統有漏氣，應先檢查管路連接處是否鬆脫。氣泡可能是來自胸膜腔（氣胸）或系統連接處，必須從胸壁穿刺點順著管路向引流瓶逐一檢查並加強固定，夾管（Clamp）為最後手段且風險高，不可輕易執行。
Continuous bubbling in the water seal chamber indicates a leak in the system, so the nurse should first check the tubing connections for any loose fittings. The air may originate from the pleural cavity (pneumothorax) or from a connection in the system, and the entire tubing must be inspected step by step from the chest wall insertion site down to the drainage unit and secured. Clamping the tube is a last-resort maneuver with high risk and should not be performed lightly.
美台皆重視胸管照護的氣密性，美國護理師對胸管異常處置之自主性較高，台灣臨床護理師常在醫師監督下處理管路異常。