— 降低風險 · MEDIUM · MCQ —
護理師照護一位放置胸管連接密閉引流系統的病人，發現水封瓶持續冒泡。護理師首要採取的行動為何？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. The nurse observes continuous bubbling in the water seal chamber. What is the nurse's priority action?
- ACheck the connections from the insertion site to the unit✓ 正解檢查從插入部位到引流單位的連接處
- BIncrease the suction pressure增加抽吸壓力
- CClamp the chest tube to find the leak夾住胸管以找出漏氣處
- DNotify the provider immediately立即通知醫師
— Explanation · 中文詳解 —
水封瓶持續冒泡通常意味著系統發生空氣洩漏。護理師應採取系統化的檢查方式，首先從插入處開始沿著管路檢查所有連接點是否鬆脫。若夾住管路後冒泡停止，則洩漏點在管路系統中；若仍冒泡，則可能為病人肺部空氣洩漏。應先排除管路連接問題再回報，以維持系統完整性。
Continuous bubbling in the water-seal chamber typically indicates an air leak within the drainage system rather than normal lung drainage. The nurse's priority action is to systematically check all connections from the insertion site to the collection unit to identify and secure any loose fittings before notifying the provider.
✦ 台美臨床差異
美台臨床皆高度重視胸管照護，但美國護理師常需在床邊自行解決設備問題，台灣則常依賴專科護理師或醫師協助調整。