護理師照護一位放置胸管的病患，應採取哪些措施？（選所有適合的）
A nurse is caring for a client with a chest tube. Which actions should the nurse perform? (Select all that apply.)
- AKeep the drainage system below the level of the chest✓ 正解保持引流系統低於胸腔水平
- BClamp the chest tube when the patient is ambulating當病人下床活動時夾住胸管
- CAssess for bubbling in the water-seal chamber✓ 正解評估水封瓶內是否有氣泡
- DSecure all connections with tape✓ 正解用膠帶固定所有連接處
- EEnsure the dressing remains occlusive✓ 正解確保敷料保持密閉
胸管照護重點：引流系統低於胸腔以防液體逆流（A）；觀察水封瓶水面波動或氣泡，確認氣胸排除狀態（C）；維持連接處密封以免漏氣（D）；敷料需密閉以防外部空氣進入（E）。夾住胸管會導致張力性氣胸，除非經醫師醫囑且有特定目的（如拔管前測試），否則嚴禁夾管（B）。
The drainage system must be kept below the level of the chest to allow gravity to facilitate drainage and prevent backflow into the pleural space. Nurses should assess the water-seal chamber for bubbling to monitor air escape and ensure all connections are securely taped to maintain the closed system. The dressing must remain occlusive to prevent air entry, and the tube should never be clamped unless specifically ordered, as this can cause a tension pneumothorax.
美國護理指引對於水封瓶的氣泡評估極為嚴格，台灣臨床常使用傳統水下引流瓶，操作觀念一致，但固定材料選擇略有差異。