While conducting hourly rounding on a medical-surgical unit, a nurse discovers that a client's central venous catheter (CVC) tubing has become disconnected at the hub. The client is suddenly grasping their chest, gasping for air, and exhibiting circumoral cyanosis. To prevent further catastrophic injury from a suspected air embolism, arrange the following immediate nursing actions in the correct priority sequence.
- 1Clamp the central venous catheter immediately.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer 100% supplemental oxygen via a non-rebreather mask.
- 4Activate the facility's rapid response team.
- 5Obtain a complete set of vital signs and remain continuously with the client.
Answer
The correct priority sequence is: Clamp the catheter, position the client in left lateral Trendelenburg, administer 100% oxygen, activate the rapid response team, and then obtain vital signs while remaining with the client.
In any sudden equipment failure leading to a life-threatening error (like a CVC disconnection), the absolute first priority is source control to halt the ongoing injury. Clamping the line stops the influx of air. Immediately after, the nurse must physically manipulate the existing hazard by placing the client in a left lateral Trendelenburg position; this uses gravity to trap the air in the right ventricle, preventing it from obstructing pulmonary blood flow. Once the mechanical threat is contained, the nurse treats the physiological effects by applying 100% oxygen, which combats hypoxia and helps dissolve the nitrogen-rich air bubble. Only after these immediate, independent, life-saving actions are complete should the nurse divert attention to activating the rapid response team and gathering comprehensive assessment data (vital signs).
Step-by-Step Solution
Key Concept
Emergency management and injury prevention for a central line-associated air embolism.
Estimated Time:2m 0s