— 生理適應 · MEDIUM · MCQ —
病人的胸管不慎脫落，護理師首要採取的行動為何？
A nurse is caring for a client with a chest tube that has become dislodged. What is the priority nursing action?
- APlace the end of the tube in sterile water將管末端置於無菌水中
- BApply a sterile occlusive dressing taped on three sides✓ 正解貼上三邊封閉的無菌密閉敷料
- CReinsert the chest tube immediately立即重新插入胸管
- DCall the physician immediately立即通知醫師
— Explanation · 中文詳解 —
胸管意外脫出時，為了防止空氣大量經由胸壁傷口進入胸腔導致張力性氣胸，需立即使用無菌敷料封閉傷口。採三邊黏貼方式可形成「單向閥」，讓空氣可以排出但不會進入胸腔。此舉能爭取時間並穩定病人呼吸狀況，是護理師處理此緊急事件的黃金準則。
If a chest tube becomes dislodged, the priority is to prevent air from entering the pleural space, which could cause a tension pneumothorax. The nurse should immediately cover the site with a sterile occlusive dressing taped on three sides to act as a one-way valve, allowing air to escape but not enter.
✦ 台美臨床差異
美台臨床皆高度強調張力性氣胸的預防，此處置流程在兩地標準程序中均相同。