A nurse is caring for a client who is receiving intravenous fluids via a central venous catheter. The nurse notices that the IV tubing has accidentally disconnected from the catheter hub. The client suddenly reports severe shortness of breath and exhibits cyanosis, tachycardia, and a loud, churning murmur over the precordium. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed, from first to last.
- 1Clamp the central venous catheter.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer high-flow oxygen via a non-rebreather mask.
- 4Activate the rapid response team and notify the healthcare provider.
- 5Monitor vital signs and document the client's status.
Answer
The correct sequence is to first clamp the central venous catheter, then place the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, activating the rapid response team, and finally monitoring and documenting the client's status.
In the event of an air embolism, prioritization follows the principle of stopping the cause, managing the immediate anatomical threat, supporting physiology, and then escalating care. Clamping the line directly stops the air entry. Left lateral Trendelenburg positioning anatomically traps the air, preventing a fatal pulmonary blockage. Oxygen supports the resulting hypoxia and helps dissolve the embolus. Only after these immediate bedside interventions should the nurse step away from direct care to call for the rapid response team, followed by ongoing monitoring.
Step-by-Step Solution
Key Concept
Management of a Central Line-Associated Air Embolism