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Difficulty: HardPhysiological Adaptation

A nurse is caring for a client who is receiving intravenous fluid therapy via a subclavian central venous catheter. The nurse enters the room and observes that the intravenous tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. Arrange the following nursing interventions in the priority sequence they should be performed, from first to last.

  1. 1Clamp the central venous catheter immediately.
  2. 2Place the client in a left lateral Trendelenburg position.
  3. 3Administer 100% supplemental oxygen via a nonrebreather mask.
  4. 4Activate the rapid response team and notify the healthcare provider.
  5. 5Obtain a complete set of vital signs and auscultate heart sounds.

Answer

The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally assess vital signs and heart sounds.
The correct priority sequence adheres to the principles of basic life support and emergency source control. When an air embolism occurs, the immediate priority is to stop further air from entering by clamping the line. The second immediate priority is positional (Durant's maneuver) to prevent the air already in the system from blocking pulmonary circulation. Once the immediate mechanical threats are mitigated, the nurse supports oxygenation, calls for advanced help, and then performs a comprehensive assessment.

Step-by-Step Solution

1
Clamp the central venous catheter immediately.
Stops further atmospheric air from entering the circulatory system.
Source control is the absolute highest priority in an emergency to prevent the condition from rapidly worsening. Even a few seconds of delay can allow a fatal amount of air to enter.
2
Place the client in a left lateral Trendelenburg position.
Traps the air bubble in the apex of the right ventricle.
This specific anatomical position (Durant's maneuver) prevents the air from migrating into the pulmonary artery, avoiding a deadly right ventricular outflow tract obstruction.
3
Administer 100% supplemental oxygen via a nonrebreather mask.
Increases blood oxygenation and helps shrink the air embolus.
High-flow oxygen treats the resulting hypoxemia and creates a nitrogen concentration gradient that promotes the rapid resorption of the air bubble into the blood.
4
Activate the rapid response team and notify the healthcare provider.
Summons advanced medical support and resources.
Once immediate independent stabilizing interventions have been performed, the nurse must obtain help for further medical management, such as potential aspiration of the air from the central line.
5
Obtain a complete set of vital signs and auscultate heart sounds.
Establishes a post-intervention hemodynamic baseline and identifies clinical signs.
After securing the airway, breathing, circulation, and calling for help, the nurse assesses the client's current status, listening for a classic 'mill wheel' murmur that confirms air in the heart.

Key Concept

Prioritization of care during a suspected central line air embolism.
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Physiological Adaptation

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