— 生理適應 · MEDIUM · MCQ —
一位接有胸腔引流瓶的病人，水封瓶持續出現氣泡。護理師優先採取的行動為何？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. The nurse notices continuous bubbling in the water-seal chamber. What is the priority action?
- AClamp the chest tube immediately立即夾住胸管
- BIncrease the suction pressure增加抽吸壓力
- CDocument the finding in the chart在病歷中記錄此發現
- DAssess the entire tubing system for air leaks✓ 正解評估整個引流管系統是否有漏氣
— Explanation · 中文詳解 —
水封瓶持續氣泡通常表示系統出現漏氣（air leak），而非正常的呼吸波動。護理師應順著管路逐一檢查是否有鬆脫或破裂。A 嚴禁隨意夾住管路，易導致張力性氣胸。B 會改變壓力，無助於漏氣診斷。D 非優先處置。
Continuous bubbling in the water-seal chamber typically indicates an air leak in the system rather than normal respiratory fluctuation. The nurse should systematically inspect the tubing for loose or broken connections. Option A is contraindicated because clamping the tube can lead to a tension pneumothorax. Option B alters system pressure and does not help identify the leak. Option C is not the priority action.
✦ 台美臨床差異
兩地護理標準皆禁止非醫師指示下的夾管行為，強調必須先確認系統密封性。