— 降低風險 · MEDIUM · MCQ —
一位病人放置了胸管。下列哪項發現需要立即通知醫師？
A nurse is caring for a client who has a chest tube in place. Which finding requires immediate notification to the physician?
- AFluctuation of fluid in the water seal chamber水封瓶內液面波動
- BIntermittent bubbling in the water seal chamber水封瓶內間歇性冒泡
- CThe chest tube is securely taped to the chest wall胸管已牢固固定於胸壁
- D150 mL of bright red blood drainage in the last hour✓ 正解過去一小時內引流出 150 mL 鮮紅色血液
— Explanation · 中文詳解 —
胸管引流量若在短時間內（如 1 小時）超過 100-150 mL，或顏色呈現鮮紅色，代表可能存在活動性出血，屬於緊急情況。B 與 A 皆為正常現象（分別代表空氣排出與呼吸波動），C 則是確保安全的固定措施，不需要特別通知醫師。
While fluctuation in the water seal chamber and intermittent bubbling are normal findings indicating system patency and air evacuation, sudden drainage of bright red blood signals active hemorrhage. Immediate notification is required for excessive or fresh bloody output, as it suggests a life-threatening complication that needs urgent medical intervention.
✦ 台美臨床差異
胸管護理在兩地皆為高風險項目，台灣護理師通常需詳細記錄引流量並定時觀察顏色變化。