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Difficulty: HardPhysiological Adaptation

A nurse is caring for a client receiving intravenous fluids via a central venous catheter. The nurse enters the room and observes that the IV tubing has disconnected from the catheter hub. The client is suddenly exhibiting severe dyspnea, tachycardia, and expresses a feeling of impending doom. Arrange the following nursing actions in the correct order of priority.

  1. 1Clamp the central venous catheter immediately.
  2. 2Position the client in the left lateral Trendelenburg position.
  3. 3Administer 100% high-flow oxygen via a non-rebreather mask.
  4. 4Activate the Rapid Response Team and notify the healthcare provider.
  5. 5Obtain a complete set of vital signs and initiate continuous cardiac monitoring.

Answer

The correct sequence is to first clamp the catheter, then place the client in the left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the healthcare team, and finally obtaining vital signs.
In the event of a suspected air embolism from a central venous catheter, the nurse must act immediately to stop the air entry by clamping the line. The next physiological priority is to prevent the air bubble from traveling to the pulmonary circulation by placing the client in the left lateral Trendelenburg position. Once the air is trapped and further entry is prevented, oxygenation is supported with 100% oxygen to treat hypoxemia and shrink the nitrogen bubble. Only after these immediate life-saving actions are complete should the nurse call for advanced help and gather assessment data like vital signs.

Step-by-Step Solution

1
Clamp the central venous catheter immediately.
Prevents further air from entering the circulatory system.
When an air embolism is suspected due to a disconnected central line, eliminating the source of air entry is the highest priority.
2
Position the client in the left lateral Trendelenburg position.
Displaces the air embolus to the right ventricular apex.
This positioning prevents the air from migrating into the pulmonary arterial circulation, which would cause an obstruction.
3
Administer 100% high-flow oxygen via a non-rebreather mask.
Treats hypoxemia and accelerates nitrogen absorption.
High concentrations of oxygen reduce the size of the air bubble by creating a diffusion gradient that pulls nitrogen out of the embolus.
4
Activate the Rapid Response Team and notify the healthcare provider.
Escalates care and brings advanced support to the bedside.
The client has experienced a life-threatening complication requiring advanced medical interventions and potential transfer to the intensive care unit.
5
Obtain a complete set of vital signs and initiate continuous cardiac monitoring.
Provides objective data on the client's hemodynamic status.
Assessment follows life-saving interventions to evaluate the client's response and detect complications like arrhythmias or shock.

Key Concept

Management of a Central Venous Catheter Air Embolism
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Topics

Physiological Adaptation

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