— 降低風險 · EASY · MCQ —
護理師照護一位使用胸管水封瓶引流的病人。下列何種發現顯示系統運作正常？
A nurse is caring for a client who has a chest tube connected to a water seal drainage system. Which finding indicates the system is working correctly?
- AContinuous bubbling in the water seal chamber水封瓶內連續冒泡
- BFluctuation of the fluid level in the water seal chamber with respiration✓ 正解水封瓶內液面隨呼吸起伏
- CAbsence of drainage in the collection chamber收集瓶內無引流液
- DThe chest tube is clamped at all times胸管始終夾閉
— Explanation · 中文詳解 —
胸管水封瓶的正常運作特徵是水封液面隨呼吸起伏（Tidaling）。連續冒泡通常代表氣胸未消除或系統漏氣，而非正常循環。胸管絕不可自行夾住，以免造成張力性氣胸。引流量若為零，需確認是否為引流目的已達成或管路阻塞。
Fluctuation of the fluid level in the water seal chamber with respiration, known as tidaling, indicates that the chest tube system is patent and functioning correctly. Continuous bubbling suggests an air leak, while absence of tidaling may indicate obstruction.
✦ 台美臨床差異
美國護理師對胸管護理的評估與處置權限較高，台灣臨床對胸管夾閉的教育非常嚴格，護理師需確認醫囑方可執行。