一位肺葉切除術後的病患接有胸管，下列哪些發現需護理師立即介入？（選所有適合的）
A nurse is caring for a client with a chest tube following a lobectomy. Which findings would require immediate intervention by the nurse? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- B200 mL of bright red blood in the drainage chamber within 1 hour✓ 正解一小時內引流瓶內有 200 mL 鮮紅色血液
- CSubcutaneous emphysema around the insertion site插入點周圍的皮下氣腫
- DThe chest tube is disconnected from the drainage system✓ 正解胸管與引流系統斷開連接
- EFluctuation of the fluid level in the water seal chamber during inhalation水封瓶內液面在吸氣時波動
胸管護理重點在於監測氣胸與引流異常。A表示存在氣漏，需檢查系統連結；B表示大量出血（>100 mL/hr），需立即回報；D為系統斷開，易導致氣胸與感染，屬緊急狀況。C雖異常但通常非立即生命威脅；E為正常呼吸運動現象，無需擔心。
Continuous bubbling in the water seal chamber indicates a significant air leak, while excessive drainage of bright red blood suggests active hemorrhage, both requiring immediate intervention. Additionally, a disconnected chest tube poses a high risk for tension pneumothorax and infection, necessitating urgent reattachment. While subcutaneous emphysema requires monitoring, it is less urgent than these critical issues, and fluctuation in the water seal chamber is a normal finding.
台灣胸管護理多由專科護理師或醫師執行系統更換，美國護理師依據特定訓練標準可執行更換與評估。