— 生理適應 · HARD · MCQ —
病人的胸管水封瓶出現持續性氣泡，護理師應優先採取何種行動？
A client with a chest tube has continuous bubbling in the water seal chamber. What is the priority nursing action?
- ANotify the physician immediately立即通知醫師
- BCheck the system for air leaks✓ 正解檢查系統是否有漏氣
- CClamp the chest tube夾閉胸管
- DIncrease the suction pressure增加抽吸壓力
— Explanation · 中文詳解 —
水封瓶持續性氣泡（Continuous bubbling）通常代表系統中有空氣洩漏（Air leak）。優先步驟是檢查連接處的密合度。A 為危險動作可能造成張力性氣胸；D 會加劇漏氣或造成胸膜損傷；D 為排除洩漏失敗後的步驟。
Continuous bubbling in the water-seal chamber generally indicates an air leak within the system. The priority step is to inspect the connections for tightness. Option C is a dangerous action that may produce a tension pneumothorax; option D would worsen the leak or cause pleural injury; option A should be performed only after troubleshooting the leak has failed.
✦ 台美臨床差異
美國護理指引嚴格限制夾閉胸管；台灣臨床若發生系統故障，護理師通常會立即請資深護理師協助並同時通知醫師。