— 生理適應 · MEDIUM · MCQ —
護理師照顧一位放置胸管的病人，發現水封瓶持續冒泡。護理師應懷疑什麼問題？
A nurse is caring for a client with a chest tube. The nurse observes continuous bubbling in the water seal chamber. What should the nurse suspect?
- AThe system is functioning correctly系統運作正常
- BThe lung has fully re-expanded肺部已完全復張
- CThere is an air leak in the system✓ 正解系統有漏氣
- DThe chest tube is obstructed胸管阻塞
— Explanation · 中文詳解 —
水封瓶應只有在病人咳嗽或深呼吸時有間歇性冒泡（代表氣體排出）。若出現持續冒泡（Continuous bubbling），表示引流系統有空氣洩漏（Air leak）。需檢查接頭密合度，排除管路系統異常，避免空氣誤入胸腔影響復張。
The water-seal chamber should show intermittent bubbling only when the patient coughs or breathes deeply (indicating evacuation of air). Continuous bubbling indicates an air leak in the drainage system. The connections should be checked for proper seal and any system abnormality should be ruled out, to prevent air from entering the pleural cavity and impeding lung re-expansion.
✦ 台美臨床差異
美國護理師常需負責檢查系統密合，台灣護理師若發現異常通常會通知呼吸治療師或醫師評估。