— 生理適應 · HARD · MCQ —
一位胸管置入且連接吸引引流系統的病人，護理師觀察到水封瓶（water seal）持續冒泡。下列哪項措施最正確？
A nurse is caring for a client with a chest tube connected to a suction drainage system. The nurse observes continuous bubbling in the water seal chamber. Which action is appropriate?
- AIncrease the suction pressure增加吸引壓力
- BDocument this finding in the chart將此發現記錄於病歷中
- CCheck the connections between the chest tube and the drainage system✓ 正解檢查胸管與引流系統之間的連接處
- DClamp the chest tube near the insertion site在插入部位附近夾住胸管
— Explanation · 中文詳解 —
胸管水封瓶（water seal chamber）的波動（fluctuation）是正常的生理現象，但若出現「持續冒泡」（continuous bubbling），則代表系統內有空氣洩漏。護理師應立即檢查整個管路系統，包含管路連接處、引流瓶蓋等，以確保系統密閉。若檢查後仍持續冒泡且病人呼吸困難，則可能涉及氣胸復發或病人的肺部氣道漏氣，需立即通知醫師處理。
Continuous bubbling in the water seal chamber indicates an air leak within the chest drainage system, which is an abnormal finding. The nurse should immediately check all connections between the chest tube and the drainage system to ensure the setup is airtight and secure.