— 生理適應 · MEDIUM · MCQ —
護理師照護一位放置胸管引流系統的病人，哪項發現需要立即介入？
A nurse is caring for a client with a chest tube drainage system. Which finding requires immediate intervention?
- ADependent loops in the drainage tubing引流管路中有下垂的環狀彎曲
- BContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- CDark red drainage in the collection chamber收集瓶內有暗紅色引流液
- DFluctuation of water in the water seal chamber水封瓶內水位隨呼吸波動
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）代表胸腔內有空氣持續外漏，通常意指管路接頭鬆脫或肺部有瘻管，是嚴重的臨床警訊。D 選項為正常呼吸週期波動；A 選項需修正但非立即生命威脅；C 選項為術後初期常見表現。
Continuous bubbling in the water seal chamber indicates an air leak within the chest tube system, which requires immediate assessment and intervention to restore integrity. Other findings such as dependent loops, dark red drainage, or normal fluctuation are either non-emergent or expected postoperative findings.
✦ 台美臨床差異
美國護理師常被訓練親自檢查胸管連接處；台灣臨床多由專科護理師或胸腔外科醫師確認，護理師職責較偏向監控與回報。