A client receiving intravenous fluids via a central venous catheter suddenly develops severe shortness of breath, chest pain, and lightheadedness. The nurse notes that the catheter's injection cap has fallen off and the lumen is open to room air. Suspecting an air embolism, in what order should the nurse perform the following actions to reduce the risk of further physiological compromise? Arrange the interventions from first to last.
- 1Clamp the central venous catheter.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Activate the rapid response team.
- 5Obtain a complete set of vital signs.
Answer
The correct sequence is to first clamp the central venous catheter, then place the client in the left lateral Trendelenburg position, administer 100% oxygen, activate the rapid response team, and finally obtain a complete set of vital signs.
The priority in any acute complication is to stop the cause and prevent imminent physiological collapse. Clamping the line directly stops the air from entering. The left lateral Trendelenburg position immediately mitigates the mechanical threat of the air bubble. High-flow oxygen is then applied to treat hypoxia and shrink the bubble. Only after these immediate stabilization actions should the nurse take the time to activate the rapid response team and collect vital signs.
Step-by-Step Solution
Key Concept
In the event of a suspected air embolism from a central venous catheter, the nurse's immediate priorities are to stop further air entry, position the client to trap the air, and provide oxygenation before seeking further assistance.