— 生理適應 · HARD · MCQ —
護理師照顧一位放置胸管的病人，發現水封瓶內的液面不再隨呼吸起伏。最可能的原因為何？
A nurse is caring for a client with a chest tube. The nurse observes that the fluid in the water seal chamber stops fluctuating. What is the most likely cause?
- AThe lung has re-expanded✓ 正解肺部已復張
- BThe tubing is kinked管路扭曲
- CThe system has a leak系統有洩漏
- DTension pneumothorax is developing正發展為張力性氣胸
— Explanation · 中文詳解 —
胸管水封瓶波動停止通常有兩大原因：一是肺部已完全擴張（這是正常且良好的進展），二是管路阻塞（異常）。若生命徵象穩定，首先考慮肺部復張。B 若有洩漏會產生氣泡；C 若打結需排除；D 則會伴隨嚴重的呼吸窘迫。
Cessation of fluctuation in the water seal chamber of a chest tube generally has two main causes: full re-expansion of the lung (a normal and favorable progression) or tubing obstruction (abnormal). If vital signs are stable, full lung re-expansion should be considered first. C would produce bubbling if a leak were present; C requires ruling out kinking; D would be accompanied by severe respiratory distress.
✦ 台美臨床差異
兩地胸管護理標準一致，重點在於評估波動停止是否伴隨病人呼吸狀態的改變。