— 生理適應 · HARD · MCQ —
護理師照顧一位放置胸管的病患，下列哪項發現暗示可能發生併發症？
A nurse is caring for a client with a chest tube. Which assessment finding indicates a potential complication?
- ATidaling in the water seal chamber水封瓶內出現潮汐現象
- BDrainage in the collection chamber收集瓶內有引流液
- CStable respiratory rate呼吸頻率穩定
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
— Explanation · 中文詳解 —
水封瓶持續冒泡（continuous bubbling）通常代表空氣外洩（air leak），即肺部或裝置系統有裂孔。正常的運作應隨呼吸出現潮汐現象（tidaling），而非持續冒泡，持續冒泡意味著異常空氣進入。
Continuous bubbling in the water seal chamber indicates an air leak within the system or from the client’s lung, which is a potential complication requiring immediate attention. In contrast, tidaling reflects normal function, drainage is expected post-procedure, and stable respiratory rates suggest the client is compensating well.
✦ 台美臨床差異
台美對胸管護理的原則一致，但美國護理師在確認 air leak 定位上常需獨立執行 clamping 測試。