A practical nurse enters the room of a client receiving intravenous fluids via a central venous catheter. The nurse observes that the intravenous tubing has become disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. In which order should the nurse perform the following emergency actions to mitigate the risk of a fatal complication? Arrange the steps from first (highest priority) to last.
- 1Clamp the open lumen of the central venous catheter.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer high-flow oxygen via a non-rebreather mask.
- 4Activate the facility emergency response team and inform the supervising nurse.
- 5Assess the client's vital signs and oxygen saturation.
Answer
The correct sequence of actions for a suspected air embolism is to first clamp the catheter, then position the client in the left lateral Trendelenburg position, followed by administering high-flow oxygen, activating the emergency response team, and finally obtaining a full set of vital signs.
When an air embolism is suspected due to a disconnected central line, the immediate goal is to prevent further air entry and minimize the physiological impact of the air already introduced. The nurse must first clamp the catheter to eliminate the source of the leak. Next, the left lateral Trendelenburg position is utilized to physically trap the air in the apex of the right ventricle. Oxygen is then applied to treat severe hypoxia and help dissolve the embolus. With these immediate mechanical and respiratory safeguards established, the nurse activates the emergency response team and then gathers vital signs to provide objective data to the arriving medical providers.
Step-by-Step Solution
Key Concept
Reduction of risk potential during an air embolism involves immediate source control, specific protective positioning, oxygenation, and rapid escalation.