— 降低風險 · MEDIUM · MCQ —
護理師照護一位胸管引流的病人，觀察到水封瓶出現持續性冒泡。此時護理師應採取何種優先措施？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. The nurse observes continuous bubbling in the water-seal chamber. What is the priority nursing action?
- AIncrease the suction pressure增加抽吸壓力
- BClamp the chest tube夾住胸管
- CDocument the findings in the chart在病歷中記錄發現
- DCheck the entire system for air leaks✓ 正解檢查整個系統是否有漏氣
— Explanation · 中文詳解 —
胸管引流系統若出現水封瓶持續冒泡（Continuous bubbling），通常代表系統密合度不佳，空氣持續從胸腔外的連接處洩漏進來。護理師應優先檢查整個引流系統的連接處是否鬆脫、管路是否有破損，並確認穿刺部位的密封敷料是否完整。若非系統洩漏，則可能是病人氣胸未完全緩解，但優先任務是排除系統性洩漏。
The first action during a tonic-clonic seizure is to turn the client to the side to maintain a patent airway and prevent aspiration of secretions. Restraints or objects placed in the mouth should never be used, as they pose significant risks of physical injury and airway obstruction.