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降低風險 · EASY · MCQ

護理師照護一位使用連續式傷口引流裝置的病人,下列哪項措施對維持引流系統完整性至關重要?

A nurse is caring for a client with a continuous wound suction device. Which action is essential to maintain the integrity of the drainage system?

  • AIrrigate the tubing with normal saline every 4 hours
    每四小時用生理食鹽水沖洗管路
  • BKeep the drainage container below the level of the wound✓ 正解
    保持引流容器低於傷口位置
  • CClamp the tubing when ambulating the client
    病人下床活動時夾住管路
  • DEmpty the canister whenever it is half full
    當集氣瓶裝到一半時就將其清空
Explanation · 中文詳解

引流裝置利用重力或負壓維持液體流出。將容器置於傷口下方利用地心引力防止引流液回流,造成傷口感染。C 選項夾住引流管通常無必要且可能阻礙引流;C 不一定要半滿才倒,但維持負壓更重要;D 若無醫囑不可擅自沖洗管路以免增加感染風險。

A drainage system relies on gravity or negative pressure to keep fluid flowing outward. Keeping the collection chamber below the level of the wound uses gravity to prevent backflow of drainage and the resulting wound infection. Option C (clamping the drainage tube) is generally unnecessary and may impede drainage; D is incorrect because the chamber does not have to be half full before being emptied, but maintaining negative pressure is more important; D, irrigating the tubing without an order, is prohibited because it can increase the risk of infection.

✦ 台美臨床差異

美台臨床皆視引流管位置為重要安全原則,台灣護理師執行沖洗引流管時須極為嚴謹核對醫囑。

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