— 照護管理 · MEDIUM · MCQ —
護理師照護一位因氣胸置入胸管的病人，胸管引流系統正在劇烈冒泡。這表示什麼？
A nurse is caring for a client with a chest tube inserted for a pneumothorax. The chest tube drainage system is bubbling vigorously. What does this indicate?
- AThe lung has fully re-expanded肺部已完全復張
- BThe drainage is normal引流屬正常現象
- CThe client needs suction applied病人需要施加吸引
- DThere is an air leak in the system✓ 正解系統中存在漏氣
— Explanation · 中文詳解 —
胸管引流系統在水封瓶（Water Seal）若出現持續且劇烈的冒泡，通常表示胸腔內有空氣持續漏出（Air Leak）。這可能是系統接頭鬆脫、破損或肺部裂傷未癒合。護理師需立即檢查引流管路以排除系統漏氣，並評估病人是否有呼吸困難加劇，因為這可能導致張力性氣胸（Tension Pneumothorax），屬於危急狀況。
Vigorous bubbling in the water-seal chamber of a chest tube drainage system typically indicates an active air leak from the pleural space or a disconnection in the tubing. This finding requires immediate assessment to rule out system leaks or worsening pneumothorax, as opposed to normal drainage which does not cause such vigorous bubbling.