— 生理適應 · MEDIUM · SATA —
護理師照護一位新置入胸管的患者。下列哪些發現代表系統運作正常？（選所有適合的）
A nurse is caring for a client with a new chest tube. Which findings indicate the system is working properly? (Select all that apply.)
- AFluctuation of fluid in the water seal chamber with respiration✓ 正解水封瓶內液面隨呼吸起伏
- BContinuous bubbling in the water seal chamber水封瓶內持續冒泡
- CGentle bubbling in the suction control chamber✓ 正解抽吸控制瓶內有輕微冒泡
- DNo drainage in the collection chamber集液瓶無引流物
- EThe water level in the seal chamber rises and falls with inspiration and expiration✓ 正解密封瓶內水位隨吸氣和呼氣上升和下降
— Explanation · 中文詳解 —
胸管系統中，水封瓶（water seal）的液面應隨呼吸波動（tidal），若停止波動可能代表阻塞或肺部已擴張。抽吸控制瓶（suction control）出現輕微氣泡代表抽吸正常。若水封瓶出現連續氣泡（continuous bubbling），通常代表系統有空氣外漏，而非正常現象。D選項若完全無引流可能與置入時間有關，但在臨床上並非系統運作「正常」的判別標準。
To prevent infection in a client with neutropenia, the nurse should avoid items that harbor pathogens, such as fresh flowers, and strictly enforce hand hygiene. Monitoring temperature frequently is essential as fever may be the only early sign of infection, and limiting visitors to healthy adults reduces exposure to potential pathogens.
✦ 台美臨床差異
在美國，評估水封瓶氣泡是 NCLEX 必考重點；台灣臨床多使用電子引流系統（如 Thopaz），對於傳統水封瓶操作經驗較少。