— 降低風險 · HARD · MCQ —
護理師評估一位裝有胸管的病人。下列哪項發現需要立即通知醫師？
A nurse is assessing a client with a chest tube. Which finding requires immediate notification of the healthcare provider?
- AOccasional bubbling in the suction control chamber抽吸控制腔偶有氣泡
- BDrainage of 50 mL of serosanguineous fluid in 8 hours8 小時內引流 50 毫升血清血性液體
- CContinuous bubbling in the water seal chamber✓ 正解水封腔持續冒泡
- DFluctuation of water level in the water seal chamber with respiration水封腔水位隨呼吸波動
— Explanation · 中文詳解 —
水封瓶（Water seal chamber）內有持續氣泡代表系統漏氣（Air leak），需立即檢查管路與傷口並回報。隨呼吸起伏（Tidaling）是正常發現（D）；抽吸腔有氣泡（A）代表抽吸作用正常；8 小時 50 mL 引流量屬正常範圍（B）。
Continuous bubbling in the water seal chamber indicates an air leak within the chest tube system, which requires immediate investigation and provider notification. Normal findings include tidaling with respiration and occasional bubbling in the suction control chamber, while minimal drainage is also expected.
✦ 台美臨床差異
美國 NCLEX 考題常考系統漏氣的判斷；台灣臨床實務中，引流量突然增加也是醫師非常在意的指標。