— 降低風險 · HARD · MCQ —
護理師照護一位放置胸管的病人，哪項評估發現需要立即介入？
A nurse is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- AFluctuation of the fluid in the water seal chamber with respiration水封瓶內的液體隨呼吸波動
- BTidaling in the water seal chamber水封瓶內出現潮汐現象
- CDependent loops in the tubing管路中有下垂的環圈
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內有持續冒泡
— Explanation · 中文詳解 —
胸管水封瓶（water seal）內持續性氣泡（continuous bubbling）通常代表系統出現氣體外漏（air leak）。氣泡應僅在呼氣時出現，若持續不斷，表示胸腔外或胸管連接處有空氣進入，可能導致氣胸復發或肺部無法擴張。
Continuous bubbling in the water seal chamber indicates an air leak, which may compromise lung expansion or cause recurrent pneumothorax. Normal findings include tidaling with respiration, whereas dependent loops impede drainage but are less immediately critical than an active air leak.
✦ 台美臨床差異
美台皆將「持續氣泡」列為胸管護理之警示指標，護理師需檢查連接處是否鬆脫或胸管是否有破裂。