護理師正在照顧一位因氣胸而置放胸管的病人。下列哪項評估發現需要立即介入？
A nurse is caring for a client with a chest tube for a pneumothorax. Which assessment finding requires immediate intervention?
- ANo drainage for the last 8 hours過去 8 小時沒有引流
- BIntermittent bubbling in the water seal chamber水封瓶內有間歇性氣泡
- CTidalex (clamp) is placed on the chest tube✓ 正解胸管上夾了夾子 (clamp)
- DChest tube drainage of 50 mL in the last 4 hours過去 4 小時胸管引流量為 50 mL
胸管（Chest tube）系統用於排除胸膜腔內的氣體或液體，以重建負壓環境。胸管絕對禁止隨意夾閉，除非有醫囑（如在拔管前進行夾管測試）。若擅自夾閉，胸膜腔內的氣體無法排出，將導致壓力急劇升高，引發張力性氣胸（Tension pneumothorax），這是危及生命的緊急狀況。因此，發現胸管被夾閉必須立即移除夾子並評估病人呼吸狀態。
A chest tube system is used to drain air or fluid from the pleural cavity and reestablish negative intrapleural pressure. A chest tube must never be clamped arbitrarily unless there is a physician's order (for example, a clamping trial before removal). If the tube is clamped without authorization, air in the pleural cavity cannot escape, and the pressure will rise sharply, leading to a tension pneumothorax, a life-threatening emergency. Therefore, if a chest tube is found to be clamped, the clamp must be removed immediately and the patient's respiratory status reassessed.