— 生理適應 · MEDIUM · MCQ —
護理師照護一位胸管引流病人，發現水封瓶持續有氣泡冒出。這代表什麼？
A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the water seal chamber. What does this indicate?
- AThe chest tube is obstructed胸管阻塞
- BThe lung has re-expanded肺部已復張
- CThe system has an air leak✓ 正解系統有漏氣
- DThe suction pressure is too low抽吸壓力過低
— Explanation · 中文詳解 —
水封瓶（Water seal）應僅在咳嗽或深呼吸時出現間歇性氣泡。若出現「連續性氣泡」，表示系統內或病人胸腔內有氣漏現象。護理師應順著管路檢查連接處是否鬆脫。B 選項若肺部完全擴張，氣泡應消失；D 選項不影響水封瓶氣泡；A 選項則會導致氣泡停止。
Continuous bubbling in the water seal chamber indicates an air leak within the chest drainage system or from the patient's lung. Intermittent bubbling is normal during coughing or deep breathing, but constant bubbling suggests a disruption in the system integrity that requires immediate assessment of connections and tubing.
✦ 台美臨床差異
兩地胸管護理標準皆高度一致，強調密閉原則與水封瓶觀察。