— 生理適應 · HARD · MCQ —
一位帶有胸管的病人，水封瓶（water seal chamber）出現持續性氣泡，護理師應優先採取什麼行動？
A client with a chest tube has continuous bubbling in the water seal chamber. What is the nurse's priority action?
- AIncrease the suction pressure增加抽吸壓力
- BDocument the findings in the chart在病歷中記錄發現
- CCheck the tubing connections for air leaks✓ 正解檢查管路連接處是否有漏氣
- DClamp the chest tube to find the leak夾住胸管以尋找漏氣點
— Explanation · 中文詳解 —
胸管水封瓶（Water seal chamber）持續出現氣泡（Continuous bubbling）通常代表系統存在空氣洩漏（Air leak）。護理師應採取系統性評估：首先檢查管路連接處是否鬆脫，因為這是最常見的原因。若連接處無誤，則需考慮是否為病人胸膜腔內持續漏氣。護理師絕對不能在沒有醫囑的情況下隨意夾閉胸管，因為這會截斷氣體排出路徑，導致壓力累積引發張力性氣胸。
Continuous bubbling in the water seal chamber indicates an air leak, so the nurse’s priority is to systematically check tubing connections for dislodgement, which is the most common cause. Clamping the tube is contraindicated as it can lead to tension pneumothorax, and increasing suction does not resolve an existing leak.