— 生理適應 · HARD · SATA —
護理師照顧胸管置入病人，下列哪些評估結果需要立即處置？（選所有適合的）
A nurse is caring for a client with a chest tube. Which assessment findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BFluctuation of the fluid in the water seal chamber during inhalation吸氣時水封瓶內液體波動
- CSubcutaneous emphysema around the insertion site插入部位周圍有皮下氣腫
- DDark red drainage of 200 mL in the first hour✓ 正解第一小時內有 200 mL 暗紅色引流液
- ETracheal deviation toward the unaffected side✓ 正解氣管向未受損側偏移
— Explanation · 中文詳解 —
胸管系統若發生持續性氣泡（A）代表管路漏氣；第一小時引流液超過 200 mL（D）顯示活動性出血；氣管偏移（E）則暗示緊張性氣胸，均為致命性徵兆。B 與 C 雖需密切監測，但若非惡化狀況，通常屬於預期內或可控範圍。
With a chest tube, continuous bubbling (A) suggests an air leak; sanguineous drainage >200 mL in the first hour (D) suggests active bleeding; tracheal deviation (E) suggests tension pneumothorax—all life-threatening. B and C require close monitoring but, unless worsening, are usually expected or manageable findings.
✦ 台美臨床差異
台美對胸管管理原則相同，但美國護理師常受過特定訓練可自行排除管路小問題，台灣多由醫師處理插管與拔管。