— 生理適應 · MEDIUM · MCQ —
胸管引流病人出現何種徵象，護理師應立即回報醫師？
Which assessment finding in a client with a chest tube should the nurse report to the healthcare provider immediately?
- ASubcutaneous emphysema at the insertion site插入部位出現皮下氣腫
- BFluctuation in the water seal chamber with breathing水封瓶內水面隨呼吸波動
- CDrainage of 50 mL of serosanguineous fluid排出 50 mL 的血清樣滲出液
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
— Explanation · 中文詳解 —
水封瓶持續性氣泡（Continuous bubbling）暗示系統有漏氣（Air leak），若排除管路連接問題，則可能為肺部持續漏氣，需緊急處理。Fluctuation（潮汐波動）是正常呼吸變化的反應。50 mL 血清樣液體在術後初期屬於正常引流量。皮下氣腫需監測範圍，但持續漏氣對肺擴張影響更急迫。
Clients with influenza, pertussis, and meningococcal pneumonia require strict droplet precautions because these pathogens are transmitted via large respiratory droplets. In contrast, varicella and measles necessitate airborne precautions due to their transmission through smaller particles that remain suspended in the air.
✦ 台美臨床差異
台灣胸腔外科病房對於胸管護理極為嚴謹，美國護理師對胸管異常處置亦有較高的自主權限。