— 生理適應 · MEDIUM · MCQ —
護理師照顧一位置放胸管的病人。下列哪項發現應立即報告醫師？
A nurse is caring for a client with a chest tube. Which finding should the nurse report to the provider immediately?
- AFluctuation of the fluid in the water seal chamber水封瓶內液面的波動
- BSmall amount of sanguineous drainage少量血性引流液
- CContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- DThe chest tube dressing is intact and dry胸管敷料完整且乾燥
— Explanation · 中文詳解 —
胸管水封瓶（Water seal chamber）的監測是維護呼吸功能的關鍵。正常情況下，水封瓶內的水柱會隨呼吸波動（Fluctuation）。若出現「持續冒泡」（Continuous bubbling），代表胸膜腔與外界或肺部之間存在空氣洩漏（Air leak），這意味著氣胸未改善或系統密封受損，必須立即報告醫師檢查系統密閉性或個案狀況。
Continuous bubbling in the water seal chamber indicates a persistent air leak, suggesting that the pleural space is not sealed or there is a system breach, which requires immediate medical assessment. Normal findings include fluctuation of the fluid column with respiration and small amounts of sanguineous drainage, while an intact dressing is also an expected positive outcome.