護理師照顧放置胸管的病人。下列哪些護理措施應包含在照護計畫中？（選所有適合的）
A nurse is caring for a client with a chest tube. Which actions should the nurse include in the plan of care? (Select all that apply.)
- AKeep the drainage system below the level of the client's chest✓ 正解將引流系統置於病人胸部水平以下
- BClamp the chest tube if the client needs to be transported若病人需搬運，則夾住胸管
- CAssess for bubbling in the water-seal chamber✓ 正解評估水封腔是否有氣泡
- DEnsure the drainage unit remains upright✓ 正解確保引流裝置保持直立
- EStrip or milk the chest tube every 2 hours to maintain patency每兩小時擠壓或捋順胸管以維持通暢
胸管護理重點在於維持密閉與引流。引流瓶需低於胸腔以防逆流，維持垂直以確保水位功能。水封瓶泡泡是監測氣胸的重要指標。B 錯誤：嚴禁隨意夾住胸管，易引發張力性氣胸。E 錯誤：擠壓管路（Stripping）會造成過大壓力傷害胸膜，原則上已不建議。
The drainage system must be kept below the level of the client’s chest to prevent fluid from flowing back into the pleural space via gravity. Additionally, the unit should remain upright to ensure the water seal functions correctly, and the nurse must assess the water-seal chamber for bubbling, which indicates an air leak. Clamping the tube or stripping it is contraindicated as it can cause tension pneumothorax or excessive intrapleural pressure.
美國醫院多使用密閉式引流瓶系統，台灣亦同，但針對是否擠壓管路的 SOP 在不同醫院間仍有落差。