— 降低風險 · MEDIUM · MCQ —
護理師照護一位放置胸管並連接密閉式引流系統的病人，哪項評估發現需要立即處理？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. Which assessment finding requires immediate intervention?
- ASmall amount of serosanguineous drainage in the collection chamber收集室中有少量漿血性引流液
- BDependent loops of the drainage tubing引流管路出現下垂環
- CFluctuation of the fluid in the water seal chamber水封室中液體波動
- DContinuous bubbling in the water seal chamber✓ 正解水封室中持續冒泡
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）暗示系統發生氣體洩漏，應檢查管路連接點並通知醫師。若為氣胸病人，剛開始冒泡正常，但持續冒泡不屬於預期結果。B 是呼吸運動的正常現象；C 是需要糾正但非立即生命威脅；D 為術後正常引流表現。
Intravenous potassium chloride must always be administered in a diluted form to prevent severe complications such as phlebitis, tissue necrosis, or fatal cardiac arrhythmias. Direct IV bolus injection is strictly contraindicated because rapid introduction of high-concentration potassium can cause immediate heart failure. Ensuring appropriate dilution and using an infusion pump are critical safety precautions for this high-alert medication.
✦ 台美臨床差異
美台臨床對於胸管護理的護理判斷原則相似，皆強調不可隨意夾管。