— 照護管理 · HARD · MCQ —
護理師照護胸管病人，若管路意外與引流系統脫落，優先採取的措施為何？
A nurse is managing a client with a chest tube that has become disconnected from the drainage system. What is the nurse's priority action?
- APlace the distal end of the chest tube in a bottle of sterile water✓ 正解將胸管遠端置入無菌水瓶中
- BApply an occlusive dressing to the insertion site在插入處施加封閉式敷料
- CClamp the chest tube to prevent air entry夾住胸管以防止空氣進入
- DImmediately call the physician立即呼叫醫師
— Explanation · 中文詳解 —
胸管系統脫落時，胸膜腔直接與大氣相通，會造成張力性氣胸（Tension pneumothorax）。護理師應立即將管路末端置入無菌水中，建立緊急「水封（Water seal）」，防止大氣進入胸膜腔，同時維持氣體排出功能。絕不可夾住管路，因為胸腔內的氣體仍會持續產生，若無法排出將導致壓力急速上升，引發縱膈偏移。
If a chest tube becomes disconnected, the pleural cavity is exposed to atmospheric pressure, risking a tension pneumothorax. The priority action is to immerse the distal end of the tube in sterile water to create an emergency water seal, preventing air entry while avoiding clamping, which could trap air and increase intrathoracic pressure.