Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A nurse enters the room of a client receiving intravenous fluids via a subclavian central venous catheter. The nurse discovers that the intravenous tubing has become inadvertently disconnected from the catheter hub. The client suddenly reports severe chest pain and shortness of breath, and their heart rate increases to 128 beats per minute. Which of the following is the most appropriate initial nursing action?

  1. Clamp the catheter hub and immediately place the client in a left lateral Trendelenburg position.Cevap
  2. B
    Assist the client into a high-Fowler's position and prepare to obtain an arterial blood gas sample.
  3. C
    Perform a comprehensive auscultation of all lung fields to determine the extent of respiratory distress.
  4. D
    Activate the emergency response team and assess peripheral pulses to evaluate systemic circulation.

Cevap

The correct action is to clamp the catheter hub and immediately place the client in a left lateral Trendelenburg position.
The clinical scenario of a disconnected central line accompanied by sudden dyspnea and tachycardia is the classic presentation of an acute air embolism. To reduce the risk of cardiopulmonary collapse, the nurse must immediately clamp the catheter to prevent further air entry. Placing the client in the left lateral Trendelenburg position utilizes gravity to trap the air in the apex of the right ventricle, preventing it from occluding the pulmonary artery.

Adım Adım Çözüm

1
Identify the clinical emergency based on the presentation.
The disconnected central venous catheter paired with sudden respiratory distress and tachycardia strongly indicates a suspected air embolism.
Recognizing life-threatening complications quickly dictates the priority of nursing care.
2
Determine the physiological goal of the intervention.
The goal is to stop further air from entering the circulatory system and to trap the air that has already entered before it reaches the pulmonary or cerebral circulation.
Air entering the right atrium and ventricle can block blood flow to the lungs, leading to rapid cardiovascular collapse.
3
Select the appropriate action to achieve this goal.
Clamping the catheter prevents further air entry. Placing the client on their left side with the head down (left lateral Trendelenburg) traps the air bubble in the apex of the right ventricle, keeping it away from the pulmonary valve.
This specific combination of mechanical closure and gravitational positioning is the definitive first-line emergency intervention for an air embolism.

Anahtar Kavram

Management of Central Venous Catheter Complications (Air Embolism)
Tahmini Süre:1m 0s
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Konular

Reduction of Risk Potential

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