— 生理適應 · HARD · MCQ —
護理師照顧一位接有胸腔引流管的病人，發現水封瓶持續冒泡。護理師優先採取的行動為何？
A nurse is caring for a client with a chest tube connected to a closed-chest drainage system. The nurse observes continuous bubbling in the water seal chamber. What is the nurse's priority action?
- ADocument the finding as normal將此發現記錄為正常
- BCheck the connections between the patient and the drainage system✓ 正解檢查病人與引流系統之間的連接
- CIncrease the suction pressure增加抽吸壓力
- DClamp the chest tube to find the leak夾住胸腔引流管以找出漏氣處
— Explanation · 中文詳解 —
水封瓶持續冒泡通常表示系統中有空氣洩漏。優先應沿著管路檢查所有接口是否鬆脫或破損。若病人剛拔管或氣胸範圍大則可能出現，但需先排除裝置漏氣。D 選項必須謹慎，通常禁止隨意夾管以免造成張力性氣胸。C 會加劇問題。A 不正確，持續冒泡非正常現象。
Continuous bubbling in the water seal chamber indicates an air leak in the system rather than normal function. The nurse’s priority action is to systematically check all connections between the patient and the drainage system for looseness or damage. Clamping the tube is contraindicated as it risks causing a tension pneumothorax.
✦ 台美臨床差異
美國護理指引嚴格限制夾管動作以預防張力性氣胸；台灣臨床對於胸管護理亦遵循相同安全規範。