護理師照護一名裝有胸管且連接水封引流系統的病人。護理師注意到水封瓶內有持續性氣泡。這代表什麼？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. The nurse notes continuous bubbling in the water-seal chamber. What does this suggest?
- AThe client has a pneumothorax that is resolving個案患有正在緩解的氣胸
- BThe system is functioning correctly系統運作正常
- CThe suction pressure is too high吸引壓力過高
- DThere is an air leak in the system✓ 正解系統存在漏氣
這道題目考驗護理師對胸管引流系統（Chest tube drainage system）正常與異常現象的判讀能力。水封瓶（Water-seal chamber）是胸管系統的重要組成部分，用於觀察胸腔內是否有漏氣。正常情況下，如果病人有氣胸（Pneumothorax）且正在排出空氣，水封瓶會出現間歇性氣泡（Intermittent bubbling），尤其是在呼氣或咳嗽時。然而，如果水封瓶出現持續性（Continuous bubbling）的氣泡，這通常表示引流系統中存在漏氣，可能是管路連接不緊密、胸管從胸腔穿刺處漏氣，或是病人持續有大量氣胸導致氣體不斷排出。
This item tests the nurse's ability to interpret normal and abnormal findings in a chest tube drainage system. The water-seal chamber is used to observe for air leaking from the pleural space. Intermittent bubbling—especially with exhalation or coughing—is expected in a patient with a pneumothorax that is resolving. Continuous bubbling, however, generally indicates an air leak: it may originate from loose tubing connections, leakage at the chest tube insertion site, or an ongoing large pneumothorax. The nurse should systematically check the system from the connections to the insertion site to identify and correct the leak.
美國護理教育強調「Tidaling」（隨呼吸波動）的觀察；台灣臨床同樣重視，但在報告時對「Air leak」的等級描述可能略有不同。