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Question

Difficulty: HardReduction of Risk Potential

A nurse enters the room of a client receiving continuous intravenous fluids through a right subclavian central venous access device (CVAD). The nurse observes that the IV tubing has completely disconnected from the catheter hub. The client is suddenly tachypneic, diaphoretic, and reports severe, sharp chest pain. After immediately clamping the CVAD, which of the following is the nurse's priority action?

  1. Place the client in a left lateral Trendelenburg positionAnswer
  2. B
    Elevate the head of the bed to a high-Fowler's position
  3. C
    Notify the rapid response team and prepare to obtain arterial blood gases
  4. D
    Prepare to administer a rapid isotonic fluid bolus to stabilize blood pressure

Answer

Place the client in a left lateral Trendelenburg position
The client is exhibiting classic signs of a venous air embolism, a life-threatening complication caused by air entering the venous system through an open central line. Placing the client in the left lateral Trendelenburg position (Durant's maneuver) is the absolute priority. This position utilizes gravity to trap the air bubble in the apex of the right ventricle, preventing it from migrating into the right ventricular outflow tract and pulmonary artery, which would cause an acute obstructive shock.

Step-by-Step Solution

1
Analyze the clinical scenario
The client has a disconnected CVAD with sudden onset of respiratory distress and chest pain.
These findings are classic indicators of a venous air embolism, which occurs when negative intrathoracic pressure draws room air into the open venous system.
2
Identify the immediate physiological threat
Air entering the right side of the heart can block the right ventricular outflow tract and pulmonary artery, causing acute obstructive shock.
Immediate physical intervention is required to prevent the air from migrating further into the pulmonary circulation.
3
Determine the priority intervention
Placing the client in a left lateral Trendelenburg position (Durant's maneuver) traps the air in the apex of the right ventricle.
This positional change keeps the buoyant air bubble away from the pulmonary valve, maintaining cardiac output and reducing the risk of a fatal obstruction.

Key Concept

Management of Venous Air Embolism
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Topics

Reduction of Risk Potential

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