# 一位個案有胸管連接到水封式引流系統。護理師觀察到水封室有持續性氣泡。護理師應採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397336&lang=zh-tw  
> language: zh-TW  
> subject: Complications of Procedures  
> category: ROR

## 題目

一位個案有胸管連接到水封式引流系統。護理師觀察到水封室有持續性氣泡。護理師應採取哪項行動？

## 選項

1. 在剩餘的班別中夾住胸管。
2. 將引流系統抬高至胸部以上。
3. 用力擠壓管路以移除血塊。
4. 檢查系統及管路連接處是否有漏氣。 **✔ 正確答案**

**正確答案: 4**

## 解析

水封室出現持續性氣泡表示個案或引流系統有漏氣。護理師應評估系統及連接處。常規夾管、抬高引流系統或用力擠壓管路都可能造成傷害。

## 深入解析

臨床判斷
利用個案線索、時間點、檢驗數據及安全風險，選擇最符合胸管持續性氣泡的處置。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶提取。

## 臨床情境

臨床實務指引
針對胸管持續性氣泡，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **胸管** — 用於從肋膜腔移除空氣或液體的管路。
- **水封** — 一個允許空氣逸出同時防止空氣逆流回肋膜腔的腔室。
- **漏氣** — 空氣意外進入引流系統或肋膜腔。

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