— 生理適應 · MEDIUM · MCQ —
護理師照顧裝有胸管引流系統的病人，下列哪種觀察結果需要立即處理？
A nurse is caring for a client with a chest tube drainage system. Which observation requires immediate intervention?
- AThe chest tube is securely taped to the chest wall胸管已牢固固定於胸壁
- BDrainage of 50 mL serosanguinous fluid in 2 hours2小時內引流50 mL血清血性液體
- CGentle tidaling in the water seal chamber水封瓶內出現輕微潮汐波動
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）表示系統存在氣體外漏（Air leak）。正常狀況應僅在咳嗽或深呼吸時出現間歇冒泡，持續冒泡代表胸膜腔可能持續有氣體進入或接頭鬆脫，需立即找出漏氣點並檢查管路完整性。
Continuous bubbling in the water seal chamber indicates an air leak somewhere in the system. Normally, bubbling should occur only intermittently with coughing or deep breathing; continuous bubbling means that air may be entering the pleural space persistently or that a connection has loosened. The leak source must be identified immediately and the integrity of the tubing checked.
✦ 台美臨床差異
臨床對於胸管護理標準一致，但在美國護理師對引流瓶故障排除權限較大。