— 生理適應 · MEDIUM · MCQ —
一位病人的胸管脫出，護理師應立即採取的動作為何？
A nurse is caring for a client with a chest tube that has become dislodged. Which action should the nurse take immediately?
- AReinsert the tube into the pleural space將導管重新插入胸膜腔
- BPlace the client in a prone position讓病人採取俯臥姿勢
- CCover the site with a sterile petroleum gauze dressing✓ 正解以無菌凡士林紗布覆蓋傷口
- DNotify the physician immediately立即通知醫師
— Explanation · 中文詳解 —
胸管脫出是胸腔外科的緊急事件。胸腔內為負壓，一旦胸管脫出，外界空氣會瞬間灌入胸膜腔，導致張力性氣胸（Tension pneumothorax），進而引發縱膈偏移與循環衰竭。護理師應立即使用凡士林紗布（Petroleum gauze）覆蓋傷口，並用膠帶固定三面，此舉形成了一個單向閥，允許胸腔內空氣排出，但防止外界空氣進入，為病人爭取緊急處置時間。
A dislodged chest tube creates an open pneumothorax risk, allowing air to enter the pleural space and potentially causing tension pneumothorax. The nurse must immediately cover the site with a sterile occlusive dressing, such as petroleum gauze, taped on three sides to act as a one-way valve. This intervention prevents further air entry while allowing trapped air to escape, stabilizing the patient until the provider can reinsert the tube.