During a central venous access device tubing change, the catheter accidentally disconnects. The client immediately exhibits severe dyspnea, cyanosis, and tachycardia. In what order must the nurse perform the following emergency actions to mitigate the risk of a fatal air embolism?
- 1Clamp the central venous catheter immediately.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer high-flow oxygen via a non-rebreather mask.
- 4Activate the facility's rapid response system.
- 5Obtain a complete set of vital signs and oxygen saturation.
Answer
The correct emergency sequence for a suspected air embolism is to clamp the catheter, position the client in left lateral Trendelenburg, administer oxygen, activate the rapid response team, and then obtain vital signs.
In a life-threatening emergency where an active hazard is present, the first priority is to stop the source of harm (clamping the catheter). The next priority is immediate physiological stabilization to prevent the complication from becoming fatal (positioning to trap the air, followed immediately by oxygen to treat hypoxia). Once these rapid, life-saving physical actions are completed, the nurse must call for advanced medical help. Finally, continuous assessment (obtaining vital signs) is performed to monitor the client's baseline and response to treatment while waiting for the rapid response team to arrive.
Step-by-Step Solution
Key Concept
Emergency management and prioritization of an air embolism to reduce the risk of cardiopulmonary collapse.