— 生理適應 · EASY · MCQ —
一位病人的胸管不慎滑脫，護理師的首要處置為何？
A nurse is caring for a client with a chest tube that has been accidentally dislodged. What is the priority nursing action?
- ACover the site with a sterile petroleum-impregnated gauze以凡士林紗布覆蓋傷口。
- BApply an occlusive dressing and tape it on three sides✓ 正解施加封閉性敷料並在三側貼上膠帶。
- CInsert a new chest tube immediately立即插入新的胸腔引流管。
- DCall the physician to the bedside呼叫醫師到床邊。
— Explanation · 中文詳解 —
胸管（Chest tube）意外滑脫屬於胸腔科急症，會導致開放性氣胸（Open pneumothorax），使大氣壓力直接進入胸膜腔。護理師必須立即採取「三邊固定法」封閉傷口，此設計模仿單向閥原理：吸氣時敷料被吸入封閉傷口，呼氣時空氣可從未固定的那一邊排出，防止空氣堆積造成張力性氣胸（Tension pneumothorax）。這是為了維持呼吸循環穩定，爭取後續醫療處置時間的首要護理行動。
When a chest tube is accidentally dislodged, the priority is to prevent an open pneumothorax by applying an occlusive dressing taped on three sides. This technique acts like a one-way valve, allowing air to escape during exhalation while preventing atmospheric air from entering the pleural space during inhalation.