— 生理適應 · MEDIUM · MCQ —
一位病人的胸管從引流系統脫落，護理師的首要行動為何？
A nurse is caring for a client with a chest tube that has been disconnected from the drainage system. What is the priority action?
- AClamp the chest tube with padded hemostats用帶墊止血鉗夾閉胸管
- BInsert the chest tube into a bottle of sterile water✓ 正解將胸管插入無菌水瓶中
- CNotify the healthcare provider immediately立即通知醫療提供者
- DApply an occlusive dressing to the insertion site在插管處施加封閉性敷料
— Explanation · 中文詳解 —
胸管脫落時，首要目標是重建水封閥（Water seal）功能以防止空氣倒灌進入肋膜腔造成張力性氣胸。將胸管末端置入無菌水中可維持密封並允許氣體排出。絕對不可直接夾閉胸管，因可能導致張力性氣胸迅速惡化。
When a chest tube becomes disconnected, the primary goal is to re-establish the water seal function to prevent air from being drawn back into the pleural space and causing a tension pneumothorax. Placing the end of the tube into sterile water maintains the seal and allows air to escape. The chest tube must never be directly clamped, as this can rapidly worsen a tension pneumothorax.
✦ 台美臨床差異
兩地臨床規範均強調絕對禁止輕易夾管，且無菌水瓶作為緊急處置已是護理常規。