— 降低風險 · MEDIUM · MCQ —
護理師照護一位放置胸管的術後病人，發現水封瓶持續冒泡。護理師應採取的第一項優先行動為何？
A nurse is caring for a postoperative client who has a chest tube. The nurse observes continuous bubbling in the water seal chamber. What is the nurse's priority action?
- ADocument the finding as normal將此發現記錄為正常
- BClamp the chest tube immediately立即夾閉胸管
- CIncrease the suction pressure增加抽吸壓力
- DCheck the entire tubing system for air leaks✓ 正解檢查整個管路系統是否有漏氣
— Explanation · 中文詳解 —
水封瓶持續冒泡通常代表系統存在漏氣（air leak）。護理師應沿著管路系統檢查是否有鬆脫或破損，確保氣密性。夾住胸管極度危險，可能導致張力性氣胸。增加負壓會加劇漏氣，且該發現非正常狀況，必須立即排除危險源。
Continuous bubbling in the water seal chamber indicates an air leak within the drainage system that requires immediate identification and correction. The nurse should inspect the entire tubing system for loose connections or damage rather than documenting the finding as normal or clamping the tube, which could precipitate a tension pneumothorax.
✦ 台美臨床差異
美國護理師常依據病房 protocol 執行管路檢查；台灣臨床則多依據醫師醫囑進行引流管相關護理與檢查。