— 降低風險 · EASY · MCQ —
護理師照護一位放置胸管的病人，應採取哪項措施以確保引流安全？
A nurse is providing care for a client who has a chest tube. Which action should the nurse take to ensure safe drainage?
- AStrip the tubing to clear clots frequently頻繁剝離管路以清除血塊
- BEmpty the drainage container when it is full當引流容器裝滿時將其清空
- CClamp the chest tube if the client is going for a walk若病人外出散步時夾住胸管
- DKeep the drainage system below the level of the chest✓ 正解保持引流系統低於胸部水平
— Explanation · 中文詳解 —
胸管引流系統必須保持在胸部水平以下，利用重力引流並防止引流液逆流至胸膜腔。C 項夾管會造成張力性氣胸，絕對禁止；A 項剝離管路（strip）會產生高負壓，可能損傷肺組織；B 項通常在容量快滿前就要更換，而非等到全滿。
The drainage system must be kept below the level of the chest to utilize gravity for drainage and prevent fluid from flowing back into the pleural space. Stripping the tubing creates excessive negative pressure that can damage lung tissue, while clamping the tube risks causing a tension pneumothorax.
✦ 台美臨床差異
美國護理師常使用較新的乾式引流瓶，台灣則乾式與濕式水封瓶皆有使用，護理師需確認系統運作原理。