一位插有胸管的病人，護理師應採取哪些措施以維護安全？（選所有適合的）
A nurse is caring for a client with a chest tube. Which interventions should the nurse perform to maintain safety? (Select all that apply.)
- AKeep the drainage system below the level of the chest✓ 正解將引流系統保持在胸部水平以下
- BClamp the chest tube if the system needs to be changed若需更換系統時夾住胸管
- CMonitor for continuous bubbling in the water seal chamber監測水封腔內的持續冒泡現象
- DTape all connections between the chest tube and drainage device✓ 正解用膠帶固定胸管與引流裝置之間的所有連接處
- EEnsure the water seal chamber has an airtight vent確保水封腔具有密閉的通氣孔
胸管護理重點在於利用重力引流（A），故引流瓶需低於胸腔。為防止空氣漏入，所有管路接頭必須妥善黏貼（D）。B 是錯誤的，除非有醫囑或特定測試，否則嚴禁夾住胸管以免導致張力性氣胸。C 錯誤，水封瓶持續氣泡代表系統有漏氣。E 是錯誤的，水封瓶應有防止逆流設計，而非開放式透氣。
Chest tube care relies on gravity drainage (A); the drainage system must remain below the level of the chest. To prevent air from entering the system, all tubing connections must be securely taped (D). Option B is incorrect: clamping a chest tube is contraindicated unless specifically ordered or required for a defined test, as it can cause a tension pneumothorax. Option C is incorrect; continuous bubbling in the water-seal chamber indicates an air leak in the system. Option E is incorrect because the water-seal chamber must remain airtight rather than openly vented in order to maintain its function.
美台醫療院所對胸管護理的標準作業程序一致，差異在於設備品牌對氣泡監測的警示設計可能不同。