— 生理適應 · MEDIUM · MCQ —
一位胸管裝置連結水封瓶的病人，若水封瓶出現持續性冒泡，護理師應執行什麼動作？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Which action is appropriate if the nurse notes continuous bubbling in the water-seal chamber?
- ADocument the finding as normal將此發現記錄為正常
- BCheck the tube connections for leaks✓ 正解檢查管路連接處是否有漏氣
- CClamp the chest tube immediately立即夾閉胸管
- DIncrease the suction pressure增加吸引壓力
— Explanation · 中文詳解 —
胸管水封瓶（Water-seal）若出現持續性冒泡（Continuous bubbling），通常代表系統有漏氣（Air leak）。這可能是管路連接鬆脫、傷口敷料密封不全或胸管本身破損。護理師應從病人端向裝置端逐一檢查所有連接點，確認有無空氣滲漏。不可隨意夾閉胸管，以免氣體無法排出導致張力性氣胸（Tension pneumothorax）。
Continuous bubbling in the water-seal chamber indicates an air leak within the chest tube system, which may result from loose connections or a breach in the tubing. The nurse should systematically check all connections for leaks; clamping the tube is contraindicated as it risks causing a tension pneumothorax.