— 降低風險 · MEDIUM · MCQ —
護理師照護一位使用封閉式引流系統的胸管病人。若胸管與引流裝置脫落，正確的護理措施為何？
A nurse is caring for a client with a chest tube connected to a closed-drainage system. What is the correct nursing action if the chest tube becomes disconnected from the drainage device?
- ACover the insertion site with a dry dressing以乾燥敷料覆蓋插入部位
- BSubmerge the distal end of the chest tube in sterile water✓ 正解將胸管遠端浸入無菌水中
- CClamp the chest tube immediately with hemostats立即以止血鉗夾住胸管
- DPlace the client in a high Fowler's position讓病人採取高福勒氏臥位
— Explanation · 中文詳解 —
胸管脫落時，胸膜腔與外界大氣壓力直接相通，會造成張力性氣胸（Tension pneumothorax）的危險。正確的緊急處置是將胸管末端浸入無菌水中，此舉能建立「水封（Water seal）」機制，既允許胸腔內氣體排出，又防止外界空氣隨吸氣動作進入胸膜腔。這是 NCLEX 考題中針對胸管脫落的標準安全處置，能有效維持胸腔負壓。
If a chest tube becomes disconnected, the immediate priority is to submerge the distal end in sterile water to create a temporary water seal. This action prevents air from entering the pleural space during inspiration, thereby maintaining negative intrathoracic pressure and reducing the risk of tension pneumothorax until the system can be properly reconnected.