護理師照顧胸管引流病人時，下列哪些發現需立即報告醫師？（選所有適合的）
A nurse is caring for a client with a chest tube drainage system. Which findings should the nurse report to the healthcare provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- B200 mL of bright red blood drainage in one hour✓ 正解一小時內引流出 200 mL 鮮紅色血液
- COscillation in the water seal chamber with respiration水封瓶隨呼吸出現波動
- DSubcutaneous emphysema around the insertion site✓ 正解插入部位周圍出現皮下氣腫
- EAbsence of drainage after 4 hours四小時後無引流液
胸管系統中，水封瓶連續氣泡代表系統有漏氣；每小時超過 100-200mL 的鮮紅引流液暗示活動性出血；皮下氣腫顯示氣體滲入組織，需評估是否滲漏。波動（Oscillation）是正常的呼吸伴隨現象；若胸管本無大量引流，4小時無引流未必異常。
In the chest tube system, continuous bubbling in the water seal chamber indicates an air leak; drainage of more than 100-200 mL of bright red blood per hour suggests active bleeding; subcutaneous emphysema indicates that air has tracked into the tissues and requires evaluation for a leak. Oscillation is a normal finding associated with respiration; if the chest tube had only minimal output to begin with, an absence of drainage at 4 hours is not necessarily abnormal.
美台護理師對胸管異常的判斷標準一致，但美國護理師常需更主動記錄並與放射科追蹤胸部 X 光結果。