— 生理適應 · MEDIUM · MCQ —
一位安置胸管的病人皮下氣腫突然增加，護理師應優先採取何項措施？
A nurse is caring for a client with a chest tube who is experiencing a sudden increase in subcutaneous emphysema. Which action is the priority?
- ADocument the findings in the electronic health record在電子病歷中記錄此發現
- BCheck the chest tube insertion site for leaks檢查胸腔引流管插入處是否有洩漏
- CAuscultate for breath sounds✓ 正解聽診呼吸音
- DIncrease the suction pressure增加抽吸壓力
— Explanation · 中文詳解 —
皮下氣腫加劇常與胸管阻塞或氣胸惡化有關。評估肺部呼吸音（優先權：評估大於處理）能判斷氣道開放性及肺部擴張程度。若聽不到呼吸音，可能代表嚴重氣胸或導管移位。之後再檢查管路是否有漏氣（B）或調整抽吸（D）。
Sudden expansion of subcutaneous emphysema in a client with a chest tube suggests a worsening air leak or tube malposition. Following the principle of assessment before intervention, the nurse should first auscultate breath sounds to determine ventilation status and screen for tension pneumothorax. Checking the insertion site and adjusting suction follow this primary assessment.
✦ 台美臨床差異
美國護理師常依據病房常規（Protocol）進行初步評估並回報，台灣護理師通常在評估後需儘速通知資深學姊或醫師確認。