— 降低風險 · MEDIUM · MCQ —
護理師照護放置胸管的病人，發現引流瓶內液面突然停止波動。優先採取何項措施？
A nurse is caring for a client who has a chest tube and finds the drainage in the collection chamber has stopped abruptly. Which action is the priority?
- ACall the primary healthcare provider呼叫主要醫療保健提供者
- BIncrease the suction pressure增加抽吸壓力
- CMilk the chest tube to clear the clot擠壓胸管以清除血塊
- DCheck for kinks or obstructions in the tubing✓ 正解檢查管路是否有扭結或阻塞
— Explanation · 中文詳解 —
胸管引流停止首先應排除機械性阻塞。護理師應評估管路有無扭結、彎曲或壓迫，確保引流系統通暢。若排除外在阻塞後仍無引流，才考慮深層栓塞或肺部擴張問題。擠壓管路（Milking）可能造成過度胸腔負壓，對組織造成損傷，非首選處置。
When chest tube drainage stops abruptly, the nurse must first check for mechanical issues such as kinks, clamps, or obstructions in the tubing. Troubleshooting the system is the priority before notifying the provider or manipulating the tube, as physical blockage is the most common cause of sudden cessation.
✦ 台美臨床差異
美國護理師常依據病房常規進行管路評估，台灣則依據醫囑執行與觀察，兩者對於管路擠壓的臨床指引皆趨於保守。