— 生理適應 · MEDIUM · MCQ —
護理師評估胸管引流系統時，哪項發現需要立即處理？
A nurse is assessing a client with a chest tube drainage system. Which finding requires immediate intervention?
- ADrainage of 50 mL of serosanguineous fluid排出 50 mL 之漿液血性液體
- BContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- CFluctuation in the water seal chamber水封瓶內液面波動
- DThe chest tube is secured with tape胸管已以膠帶固定
— Explanation · 中文詳解 —
胸管引流系統（Chest tube drainage system）水封瓶的運作狀態需密切觀察。正常情況下，水封瓶應隨呼吸有波動（Fluctuation），代表胸腔與引流管路通暢。若出現「持續性冒泡」（Continuous bubbling），通常代表系統存在漏氣（Air leak），這在術後早期可能正常，但若為持續性則異常，需立即檢查管路密合度。
Continuous bubbling in the water seal chamber indicates a significant air leak within the system or from the lung parenchyma, requiring immediate assessment to ensure system integrity. Unlike normal tidaling or moderate drainage, persistent bubbling suggests a complication that could compromise respiratory function.