— 生理適應 · HARD · MCQ —
一位接有胸腔引流管（水封瓶）的病人，護理師觀察到水封瓶出現持續性冒泡，優先採取哪項措施？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. What is the nurse's priority action?
- AClamp the chest tube immediately立即夾住胸腔引流管
- BCheck the connections of the drainage system for an air leak✓ 正解檢查引流系統的連接處是否有漏氣
- CNotify the physician immediately立即通知醫師
- DIncrease the suction pressure增加吸引壓力
— Explanation · 中文詳解 —
胸腔引流系統的水封瓶（Water-seal chamber）若出現持續性冒泡，代表系統內有空氣洩漏。護理師應遵循「由上而下（Systematic check）」的原則檢查管路連接處是否密封完整。切勿隨意夾住胸管，因為這可能導致氣體積聚於胸腔引發張力性氣胸（Tension pneumothorax）。
Continuous bubbling in the water-seal chamber indicates an air leak within the drainage system, so the nurse should first check all connections for integrity rather than clamping the tube, which could cause a tension pneumothorax.