— 照護管理 · MEDIUM · MCQ —
護理師正在督導新進護理師照顧胸管病人，下列哪項行為需要立即介入？
A nurse is supervising a newly licensed nurse who is caring for a client with a chest tube. Which action by the new nurse requires immediate intervention?
- AClamping the chest tube while the client is ambulating✓ 正解在病人散步時夾住胸管
- BKeeping the drainage system below the level of the client's chest將引流系統保持在低於病人胸部的位置
- CEncouraging the client to perform deep breathing exercises鼓勵病人進行深呼吸運動
- DChecking the water seal chamber for tidal fluctuations檢查水封瓶內的潮汐波動
— Explanation · 中文詳解 —
胸管（Chest tube）系統的完整性對維持胸膜腔負壓至關重要。隨意夾閉胸管會導致空氣積聚在胸膜腔內無法排出，迅速引發危及生命的張力性氣胸（Tension pneumothorax）。除非在特定情況（如更換引流瓶、懷疑系統漏氣需排查位置、或醫師醫囑下）外，護理師絕不可在無醫囑下夾閉胸管。新進護理師若做出此行為，資深護理師必須立即介入以防止病人生命危險。
Clamping a chest tube without a specific order is dangerous because it traps air in the pleural space, potentially causing a life-threatening tension pneumothorax. The chest tube system must remain open to maintain negative pressure and allow air or fluid to escape. Therefore, this action requires immediate intervention to prevent respiratory compromise.