護理師評估一位剛置入胸管的病人，哪些發現需要立即介入處理？（選所有適合的）
A nurse is assessing a client with a new chest tube. Which findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BTracheal deviation toward the unaffected side✓ 正解氣管向未受影響側偏移
- CSubcutaneous emphysema around the insertion site插入部位周圍有皮下氣腫
- DAbsence of fluctuation (tidaling) in the water seal chamber水封瓶內無波動（潮汐現象）
- EDrainage of 150 mL bright red blood in one hour✓ 正解一小時內引流 150 mL 鮮紅色血液
胸管評估重點在於系統密閉性與呼吸狀況。水封瓶持續氣泡代表系統有漏氣；氣管偏移表示可能發生張力性氣胸（生命徵象威脅）；一小時內超過 100-150mL 的鮮紅引流液提示活動性出血，皆需緊急報告醫師並處理。D 選項若肺部已完全擴張，tidaling 可能消失，非絕對緊急。
Immediate intervention is required for continuous bubbling in the water seal, which indicates a system air leak, and tracheal deviation, a sign of tension pneumothorax. Drainage exceeding 100 to 150 mL of bright red blood per hour suggests active hemorrhage needing urgent surgical consultation. While subcutaneous emphysema and lack of tidaling require monitoring, they are not always immediate emergencies depending on clinical context.
美國護理師對胸管引流系統的評估極為嚴格，通常需隨時攜帶夾管鉗以備漏氣處理；台灣護理師執行頻率亦高，但對於系統漏氣的決策權限較受限。