A registered nurse is performing a tubing change on a client's central venous catheter (CVC). Suddenly, the client gasps, complains of sharp chest pain, and becomes acutely dyspneic. The client's oxygen saturation drops to 84%. Recognizing a potential air embolism, arrange the following nursing interventions in the correct order of priority from first to last.
- 1Clamp the central venous catheter immediately.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Notify the rapid response team and the healthcare provider.
- 5Document the clinical presentation, interventions provided, and the client's response.
Answer
The correct priority sequence is: Clamp the central venous catheter, place the client in the left lateral Trendelenburg position, administer 100% oxygen via a non-rebreather mask, notify the rapid response team and healthcare provider, and finally document the event.
When an air embolism is suspected, prioritizing interventions based on immediate survival is essential. The nurse must first stop the source of the problem by clamping the catheter. Next, positioning the client in a left lateral Trendelenburg position traps the air in the right heart, preventing pulmonary obstruction. Oxygen administration follows to treat hypoxemia and speed up nitrogen resorption. Finally, the nurse calls for emergency help and later documents the findings.
Step-by-Step Solution
Key Concept
Prioritization of interventions for a suspected air embolism involves immediate cessation of air entry (clamping), protective positioning (left lateral Trendelenburg), oxygenation, and escalation of care.
Estimated Time:1m 0s