— 生理適應 · HARD · MCQ —
護理師觀察胸管引流病人，下列何種評估結果顯示病人出現張力性氣胸？
Which assessment finding by the nurse indicates that a client with a chest tube is experiencing a tension pneumothorax?
- ADiminished breath sounds on the affected side患側呼吸音減弱
- BTracheal deviation to the unaffected side✓ 正解氣管向未患側偏移
- CIncreased bubbling in the water seal chamber水封瓶內氣泡增加
- DDecreased heart rate with hypertension心率減慢伴隨高血壓
— Explanation · 中文詳解 —
張力性氣胸會導致胸腔內壓力劇增，將縱膈腔推向對側，進而造成氣管偏移。這是一種危及生命的急症，會壓迫心臟與大血管，導致靜脈回流受阻與心輸出量下降。相較於其他選項，氣管偏移是其最具特徵性且危急的臨床表徵。
Tension pneumothorax causes a marked rise in intrathoracic pressure that pushes the mediastinum toward the unaffected side, producing tracheal deviation. This life-threatening emergency compresses the heart and great vessels, impairing venous return and reducing cardiac output. Among the listed findings, tracheal deviation is its most specific and ominous clinical sign.
✦ 台美臨床差異
台灣胸腔外科病房對於胸管照護極為嚴謹，張力性氣胸發生時通常會由專科醫師執行緊急減壓。