— 降低風險 · HARD · MCQ —
護理師照護一位胸管引流的病人，觀察到水封瓶出現持續性氣泡，應採取什麼行動？
A nurse is caring for a client with a chest tube. The nurse observes continuous bubbling in the water seal chamber. Which action is appropriate?
- ACheck the entire system for air leaks✓ 正解檢查整個系統是否有漏氣
- BIncrease the suction pressure增加抽吸壓力
- CDocument the finding as normal將此發現記錄為正常
- DClamp the chest tube immediately立即夾住胸管
— Explanation · 中文詳解 —
胸管（chest tube）的水封瓶（water seal chamber）在正常情況下僅隨呼吸波動。若出現「持續性」氣泡，代表系統存在漏氣（air leak）。護理師應順著管路逐段檢查，確認接頭是否鬆脫、破損或引流瓶密封不全。這是確保胸管壓力平衡與引流有效性的必要行動，若不處理可能導致張力性氣胸，危及生命。
Continuous bubbling in the water seal chamber indicates an air leak within the chest tube system, which is not a normal finding. The nurse should systematically check the entire tubing and connections for loose fittings or damage to identify and correct the source of the leak.