# 為有胸管的個案翻身時，胸腔引流系統與胸管管路分離。護理師第一步應做什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393681&lang=zh-tw  
> language: zh-TW  
> subject: Complications of Procedures  
> category: ROR

## 題目

為有胸管的個案翻身時，胸腔引流系統與胸管管路分離。護理師第一步應做什麼？

## 選項

1. 將胸管夾住直到本班結束。
2. 擠壓管路以移除可能血塊。
3. 將胸管管路遠端放入無菌水中。 **✔ 正確答案**
4. 將引流系統抬高到胸部以上。

**正確答案: 3**

## 解析

胸管系統分離可能讓空氣進入肋膜腔。將管路遠端放入無菌水可在取得協助與新引流系統前建立暫時 water seal。例行夾管、擠壓管路或抬高引流系統可能造成傷害。

## 深入解析

臨床判斷
快速恢復 water seal，以防空氣進入肋膜腔。

記憶重點
胸管脫接：先無菌水封，再換新系統。

## 臨床情境

實務指引
Open RN advanced skills 指出，若管路與引流系統分離，可使用無菌水或食鹽水建立暫時 water seal。

注意
區分管路分離與胸管拔出；胸管拔出需密閉敷料並通知醫療人員。

## 重要概念

- **胸管** — 置於肋膜腔以移除空氣或液體並支持肺擴張的管路。
- **Water seal** — 讓空氣離開肋膜腔但防止空氣回流的一向性封閉。
- **肋膜腔** — 臟層與壁層肋膜間的空間，異常空氣或液體會影響肺擴張。

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