— 生理適應 · MEDIUM · MCQ —
護理師照護一位新置入胸管的病人。哪一項發現應立即通報醫師？
A nurse is caring for a client with a new chest tube. Which finding should be reported to the provider immediately?
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BSerosanguinous drainage in the collection chamber收集瓶內有漿血性引流液
- CFluctuation of the water in the water seal chamber水封瓶內水面波動
- DSlight redness at the insertion site插管處輕微紅腫
— Explanation · 中文詳解 —
胸管系統的水封瓶（Water seal chamber）功能在於防止空氣進入胸腔。正常情況下，呼氣時水面會隨呼吸波動，但不應持續冒泡。持續性冒泡（Continuous bubbling）通常代表空氣外漏（Air leak），若發生在術後初期，需密切監測系統氣密性；若持續存在，必須立即通報醫師，以防張力性氣胸的發生。
While tidaling in the water seal chamber is a normal finding indicating tube patency, continuous bubbling suggests a persistent air leak in the system or pleural space. This requires immediate reporting to the provider to assess for complications such as a tension pneumothorax, unlike serosanguinous drainage or slight redness which are expected findings.