A practical nurse (PN) is in the room with a client who has a continuous intravenous infusion via a central venous catheter. The client suddenly gasps for air, becomes profoundly cyanotic, and reports acute, severe chest pain. Suspecting a central line air embolism, arrange the following nursing actions in the precise priority order the PN should perform them to mitigate the immediate risk of a fatal complication.
- 1Clamp the central venous catheter immediately.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer high-flow oxygen via a non-rebreather mask.
- 4Notify the supervising registered nurse (RN) and the rapid response team.
- 5Obtain a complete set of vital signs while remaining with the client.
Answer
The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the RN and rapid response team, and finally obtaining a complete set of vital signs.
In a suspected central line air embolism, the sequence of actions must prioritize immediate source containment and physiological mitigation before escalating the situation. Clamping the line instantly stops the cause. The left lateral Trendelenburg position (Durant's maneuver) is the definitive mechanical intervention to trap the air in the right ventricle, preventing a fatal pulmonary embolism. High-flow oxygen helps wash out nitrogen to shrink the embolus. Only after these rapid, life-saving measures are executed should the practical nurse take the time to escalate the emergency to the RN and Rapid Response Team, followed by continuous vital sign monitoring to prepare for their arrival.
Step-by-Step Solution
Key Concept
Emergency management and prioritization of a central line air embolism