— 生理適應 · HARD · MCQ —
一位胸管留置的病人，護理師觀察到水封瓶出現持續性氣泡。首要的護理處置為何？
A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the water seal chamber. What is the priority nursing action?
- AIncrease the suction pressure增加抽吸壓力
- BCheck the insertion site for subcutaneous emphysema檢查插入部位是否有皮下氣腫
- CAssess the system for an air leak✓ 正解評估系統是否有漏氣
- DClamp the chest tube immediately立即夾住胸管
— Explanation · 中文詳解 —
水封瓶出現持續性氣泡代表系統中存在空氣洩漏。護理師應順著管路進行檢查（如接頭是否鬆脫、瓶身是否有裂縫），以確認洩漏源頭。若排除系統洩漏仍有氣泡，則需評估病人是否出現氣胸復發。夾住胸管極度危險，可能引發張力性氣胸。
Continuous bubbling in the water-seal chamber indicates an air leak in the system. The nurse should inspect along the tubing (looking for loose connections or cracks in the chamber) to identify the source of the leak. If a system leak has been ruled out and bubbling persists, the patient should be evaluated for recurrence of pneumothorax. Clamping the chest tube is extremely dangerous and may produce a tension pneumothorax.
✦ 台美臨床差異
台美兩地皆嚴格禁止未經醫囑夾胸管，臨床教學中均強調此安全準則。