— 降低風險 · MEDIUM · MCQ —
一位病人使用胸腔引流管連接水封瓶，護理師觀察到水封瓶出現持續性氣泡。護理師應採取何種行動？
A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. Which action should the nurse take?
- AIncrease the suction pressure增加抽吸壓力
- BClamp the chest tube close to the insertion site在插入部位附近夾閉胸管
- CDocument this as a normal finding將其記錄為正常發現
- DCheck the entire system for air leaks✓ 正解檢查整個系統是否有漏氣
— Explanation · 中文詳解 —
水封瓶出現持續性氣泡通常代表系統中有空氣洩漏。護理師應從連接處開始檢查，找出氣漏點並排除。這並非正常現象（除非是氣胸剛開始引流的間歇性氣泡），盲目增加抽吸壓力或夾閉管路皆可能造成病況惡化或引發張力性氣胸。
Continuous bubbling in the water-seal chamber indicates an air leak within the chest tube system, which is an abnormal finding requiring immediate investigation. The nurse should check all connections and the tubing for leaks to prevent complications, rather than clamping the tube or increasing suction pressure.
✦ 台美臨床差異
美國護理師常執行系統密封檢查及故障排除；台灣護理師若發現異常通常先通知專科護理師或醫師評估。