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Question

Difficulty: MediumEstablishing Priorities

While the nurse is changing the tubing on a client's central venous catheter, the client suddenly begins gasping for air, reports sharp chest pain, and becomes lightheaded. The nurse suspects an air embolism. In what order should the nurse perform the following actions? Arrange the actions from first to last.

  1. 1Clamp the central venous catheter.
  2. 2Place the client in the left lateral Trendelenburg position.
  3. 3Apply high-flow oxygen via a non-rebreather mask.
  4. 4Activate the rapid response team and notify the healthcare provider.
  5. 5Remain with the client and monitor vital signs.

Answer

The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, apply high-flow oxygen, activate the rapid response team, and finally remain with the client to monitor vital signs.
When an air embolism is suspected during a central venous catheter procedure, the nurse must act rapidly using a specific priority framework. The immediate first step is to eliminate the source by clamping the catheter, preventing any more air from entering the central circulation. The second critical step is positioning the client in the left lateral Trendelenburg position (Durant's maneuver); this traps the air bubble in the right atrium and apex of the right ventricle, preventing it from migrating into the pulmonary artery and causing a lethal obstruction. Once the client is positioned safely, the third step is to administer 100% high-flow oxygen, which combats hypoxia and creates a diffusion gradient to help reabsorb the nitrogen trapped in the air bubble. After these independent life-saving interventions are completed, the fourth step is to activate the rapid response team for advanced medical interventions. Finally, the nurse remains with the client to continuously monitor vital signs and respiratory status while awaiting help.

Step-by-Step Solution

1
Identify the immediate threat.
The symptoms indicate an acute central line air embolism, requiring immediate mechanical and respiratory intervention.
Recognizing the specific emergency dictates the priority framework.
2
Stop the source of harm.
Clamp the central venous catheter.
Preventing additional air from entering the bloodstream is the absolute first priority to prevent further deterioration.
3
Implement mechanical protection.
Position the client in the left lateral Trendelenburg position.
This specific position (Durant's maneuver) utilizes gravity to trap the air in the right ventricle, preventing a fatal pulmonary artery occlusion.
4
Provide respiratory support.
Administer high-flow oxygen.
Providing 100% oxygen combats systemic hypoxia and accelerates the resorption of nitrogen from the trapped air embolus.
5
Escalate care.
Activate the rapid response team.
Once initial life-saving stabilizing steps are complete, advanced medical assistance and further diagnostic testing are required.
6
Maintain assessment.
Remain with the client to monitor vital signs.
The nurse must continuously evaluate the client's physiological response to interventions until the response team takes over.

Key Concept

Prioritizing interventions for a central line air embolism involves stopping the air entry, positioning to prevent pulmonary occlusion, oxygenating, and escalating care.
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Establishing Priorities

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