A critical care nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client gasps, reports sudden severe chest pain, and becomes pale and tachycardic. Suspecting a venous air embolism, arrange the following actions in the exact priority sequence the nurse must perform them to reduce the risk of fatal cardiopulmonary collapse.
- 1Occlude the catheter insertion site immediately with a sterile, occlusive dressing.
- 2Reposition the client into the left lateral Trendelenburg position.
- 3Administer 100% high-flow oxygen via a non-rebreather face mask.
- 4Activate the hospital's emergency rapid response team.
- 5Initiate continuous hemodynamic monitoring and prepare for cardiopulmonary resuscitation.
Answer
The correct priority sequence is to first occlude the insertion site, position the client in the left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally prepare for cardiopulmonary resuscitation.
The physiological principle of managing a venous air embolism requires immediately stopping the source of the air leak, trapping the embolus to prevent pulmonary obstruction, treating the resulting hypoxemia, and then securing advanced medical help.
Step-by-Step Solution
Key Concept
Management of Venous Air Embolism