開胸術後一小時，病人的胸管引流量為 150 mL。護理師的優先行動為何？
A client with a chest tube has 150 mL of drainage in the first hour post-thoracotomy. What is the nurse's priority action?
- AClamp the chest tube夾閉胸管
- BMilk the chest tube to prevent clots擠壓胸管以防止血塊形成
- CNotify the healthcare provider✓ 正解通知醫療提供者
- DContinue to monitor hourly繼續每小時監測
此題考察護理師在胸管引流術後監測中的臨床判斷能力，尤其是在識別潛在出血併發症方面的優先次序。開胸術後，胸管引流液量的監測是評估病人術後恢復和早期發現併發症的關鍵指標。過多的胸管引流量可能提示活動性出血，這是一種需要立即處理的危急情況。 正確答案 C (Notify the healthcare provider) 是護理師的優先行動。根據臨床指引，若胸管引流量在術後第一小時內超過 100 mL，或之後持續每小時超過 70-100 mL，應立即通知醫師。病人術後一小時引流量達 150 mL，明顯超出安全範圍，提示可能存在活動性出血，這對病人的循環穩定構成嚴重威脅。立即通知醫師可以迅速啟動進一步的評估和治療，例如輸血、影像學檢查或再次手術止血。 臨床思路：在術後病人照護中，評估潛在的出血風險和維持循環穩定是護理師的最高優先事項之一（屬於循環 Circulation 的範疇）。護理師應密切監測引流液的量、顏色和性狀，並結合病人的生命徵象（如心率加快、血壓下降、尿量減少等）來判斷出血的嚴重性。及早發現並報告異常，可以有效預防併發症的惡化，確保病人安全。
This item tests the nurse's clinical judgment in monitoring chest tube drainage after thoracotomy, especially the priority of recognizing potential bleeding. Chest tube output is a key indicator of postoperative recovery and early complications. Excessive drainage may indicate active bleeding, which is a critical situation. Clinical guidelines indicate that drainage greater than 100 mL/hour in the first hour, or sustained drainage of 70-100 mL/hour thereafter, requires notification of the provider. With 150 mL in the first hour, drainage clearly exceeds the safe threshold and may indicate active bleeding, threatening hemodynamic stability. The nurse should notify the provider immediately so that further evaluation and treatment (transfusion, imaging, or re-operation) can begin promptly. Maintaining circulation and recognizing bleeding are top priorities in postoperative care.