— 降低風險 · HARD · SATA —
一位病人的胸管不慎脫落，護理師應立即採取哪些措施？（選所有適合的）
A nurse is caring for a client with a chest tube that has been accidentally removed. What should the nurse do immediately? (Select all that apply.)
- AApply a sterile occlusive dressing taped on three sides✓ 正解貼上三邊固定的無菌封閉性敷料
- BNotify the physician immediately✓ 正解立即通知醫師
- CInstruct the client to perform a Valsalva maneuver指示病人進行瓦爾薩爾氏動作（Valsalva maneuver）
- DPlace the chest tube in sterile water將胸管放入無菌水中
- EApply firm pressure over the site with a sterile gauze以無菌紗布在傷口處施加壓力
— Explanation · 中文詳解 —
胸管（Chest tube）意外脫落是嚴重的醫療緊急事件，可能導致張力性氣胸（Tension pneumothorax）。護理師的首要反應是封閉傷口，使用三邊封閉（Three-sided dressing）敷料形成單向瓣膜，使胸腔內的氣體可排出，但外界空氣無法進入。接著必須立即通知醫師，準備緊急處置。
When a chest tube is accidentally removed, the priority is to prevent air from entering the pleural space, which could cause a tension pneumothorax. The nurse should immediately apply a sterile occlusive dressing taped on three sides to create a one-way valve effect, then notify the physician for further management.