— 生理適應 · MEDIUM · MCQ —
胸腔引流管與引流系統脫落。護理師優先採取哪項行動？
A nurse is caring for a client with a chest tube that has become disconnected from the drainage system. Which action is the priority?
- AClamp the chest tube to prevent air entry夾住胸腔引流管以防止空氣進入
- BAssess the client's lung sounds immediately立即評估病人的呼吸音
- CPlace the end of the tube into a bottle of sterile water✓ 正解將管端放入裝有無菌水的瓶中
- DApply a sterile occlusive dressing覆蓋無菌閉合性敷料
— Explanation · 中文詳解 —
若胸腔引流管脫落，應立即將管末端置於無菌水中建立水封（Water seal），此舉可防止氣體進入胸腔導致張力性氣胸，同時允許氣體排出。D 選項通常用於拔管後傷口處置。A 選項是錯誤行為，因為夾住引流管可能造成張力性氣胸。B 雖然重要，但必須先恢復系統密閉性以防氣胸惡化。
The priority action is to place the chest tube end into a bottle of sterile water to immediately re-establish a water seal, which prevents air from entering the pleural space while allowing trapped air to escape. Clamping the tube is contraindicated as it can lead to a tension pneumothorax, and assessment should follow the restoration of system integrity.
✦ 台美臨床差異
台美臨床皆將「置入無菌水」視為標準作業程序，但國外護理師教育強調此動作為 Reflex Action，台灣則較依賴醫師指示。