— 降低風險 · MEDIUM · MCQ —
護理師照護一位放置胸管的病人，哪項觀察結果需要立即介入？
A nurse is caring for a client who has a chest tube. Which observation necessitates immediate intervention?
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BSmall amount of sanguineous drainage少量血性引流液
- CDressing is dry and intact敷料乾燥且完整
- DFluctuation in the water seal chamber with respiration水封瓶內隨呼吸出現波動
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）通常代表胸腔引流系統有漏氣現象（如管路連接處不緊或肺部破裂）。正常情況下，水封瓶應隨呼吸波動（Tidaling），若有間歇性冒泡則代表殘餘空氣排出，但持續性冒泡即異常。其他選項均為胸管運作的正常預期表現。
Continuous bubbling in the water seal chamber usually indicates an air leak in the chest drainage system (such as a loose connection or lung rupture). Under normal conditions, the water seal chamber should fluctuate with respiration (tidaling); intermittent bubbling indicates residual air being expelled, but continuous bubbling is abnormal. The other options represent expected normal findings of chest tube function.
✦ 台美臨床差異
美國護理師常需自行檢查管路漏氣點，台灣護理師若發現異常通常會先暫時夾管並立即通知醫師處理。