— 降低風險 · MEDIUM · SATA —
針對剛放置胸管的病人，護理師應優先監測哪些發現？（選所有適合的）
Which assessment findings should the nurse prioritize in a client with a new diagnosis of chest tube placement? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BFluctuation of the fluid level in the water seal chamber with respiration水封瓶內液面隨呼吸波動
- CSubcutaneous emphysema near the insertion site✓ 正解插管處附近有皮下氣腫
- DThe client's respiratory rate and effort✓ 正解病患的呼吸頻率與努力程度
- EThe color and amount of drainage in the collection chamber收集瓶內引流液的顏色與量
— Explanation · 中文詳解 —
胸管護理重點在於監測系統完整性與呼吸狀態。A（水封瓶持續氣泡）代表氣胸或系統漏氣，極為危險；C（皮下氣腫）代表氣體外漏至皮下；D（呼吸徵象）是病人穩定度最直接反映。B 是正常現象，E 雖需記錄但非最緊急之安全風險。
Continuous bubbling in the water seal chamber indicates an air leak or persistent pneumothorax, requiring immediate attention. Subcutaneous emphysema near the insertion site suggests air escaping into the tissues, and monitoring respiratory rate and effort is crucial for detecting distress. Tidaling is a normal finding, and while drainage should be monitored, airway and system integrity take priority.
✦ 台美臨床差異
美國護理師常直接參與胸管移除過程；台灣多為外科醫師執行移除，護理師主要負責引流系統的維護與監測。