— 降低風險 · MEDIUM · MCQ —
護理師照護一位接有水封瓶胸腔引流系統的病人，發現水封室內出現持續性氣泡。護理師應優先採取何項措施？
A nurse is caring for a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber. Which action is the priority?
- AIncrease the suction pressure增加抽吸壓力
- BCheck the system for an air leak✓ 正解檢查系統是否有漏氣
- CNotify the physician通知醫師
- DClamp the chest tube immediately立即夾閉胸腔引流管
— Explanation · 中文詳解 —
水封瓶（Water seal）胸腔引流系統中，水封室內的持續性氣泡（Continuous bubbling）通常象徵系統存在「漏氣（Air leak）」。這表示空氣正從胸腔或系統接頭處不斷進入，而非來自肺部的氣胸排氣（應為間歇性氣泡）。護理師必須優先檢查系統密合度，以防發生張力性氣胸（Tension pneumothorax）的致命風險。
Continuous bubbling in the water seal chamber indicates an air leak within the system or from the pleural space, rather than normal intermittent air expulsion. The nurse must prioritize checking the system for leaks to prevent complications like tension pneumothorax.