— 生理適應 · EASY · MCQ —
一位胸管脫離引流系統，護理師應立即採取的行動為何？
A nurse is caring for a client with a chest tube that was disconnected from the drainage system. What is the immediate action?
- ACall the physician immediately立即通知醫師
- BClamp the chest tube with padded hemostats用帶墊止血鉗夾住胸管
- CApply an occlusive dressing over the insertion site在插入部位覆蓋封閉性敷料
- DPlace the end of the chest tube in a bottle of sterile water✓ 正解將胸管末端置入裝有無菌水的瓶中
— Explanation · 中文詳解 —
當胸管脫離收集瓶時，必須建立水封（water seal）以防空氣進入胸腔導致氣胸，因此將末端置入無菌水中是恢復系統密封性的最佳方式。C 選項用於胸管整根拔出的情況；B 選項夾管可能導致張力性氣胸；D 為次要動作，先確保病人安全。
Placing the chest tube in sterile water restores the water seal, preventing air from entering the pleural space and causing a pneumothorax. Clamping the tube is contraindicated as it may lead to a tension pneumothorax.
✦ 台美臨床差異
無明顯差異，此為國際通用的緊急護理處置標準（NCLEX-RN 指南）。