護理師監測一名裝有胸管的病人。哪些發現需要立即干預？（選所有適合的）
The nurse is monitoring a client who has a chest tube. Which findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the suction control chamber負壓控制室持續冒泡
- BTracheal deviation to the unaffected side✓ 正解氣管向未受影響側偏移
- CSudden onset of shortness of breath✓ 正解突發性呼吸困難
- DFluctuation of the water level with respiration水柱隨呼吸波動
- ECrepitus felt around the insertion site✓ 正解置管部位周圍觸及捻髮音
胸管（Chest tube）是用於引流胸腔內異常積氣、積液或積血的醫療裝置，常見於氣胸、血胸或胸腔手術後。護理師監測胸管病人時，必須密切觀察引流系統的功能和病人的臨床狀況。其中，識別可能危及生命的併發症（如張力性氣胸）的早期徵象至關重要。這些徵象需要立即干預，以防止病情惡化。 本題旨在測試護理師區分正常胸管引流系統運作與危急狀況的能力，強調對病人安全的優先考量。
A chest tube is a medical device used to drain abnormal accumulations of air, fluid, or blood from the pleural cavity, commonly indicated for pneumothorax, hemothorax, or after thoracic surgery. When monitoring a patient with a chest tube, the nurse must closely observe the function of the drainage system as well as the patient's clinical status. Identifying early signs of potentially life-threatening complications, such as tension pneumothorax, is critically important. These signs require immediate intervention to prevent clinical deterioration. This question is designed to test the nurse's ability to differentiate normal chest tube drainage system function from a critical condition, emphasizing prioritization of patient safety.
胸管的護理原則，包括對引流系統的監測、對併發症的識別與處置，在美國和台灣的臨床實務中是高度標準化且一致的。對張力性氣胸、突發性呼吸困難和皮下氣腫等危急徵象的立即干預，是全球護理師應具備的核心能力。