Examkin

Soru

Zorluk: ZorAccident, Error, and Injury Prevention

During hourly rounds, a registered nurse discovers that a client's central venous catheter (CVC) has disconnected at the hub. The client suddenly gasps, becomes visibly dyspneic, and reports acute chest pain. Arrange the following nursing actions in the priority order they should be performed to prevent further catastrophic injury.

  1. 1Clamp the central venous catheter using the designated slide or pinch clamp.
  2. 2Position the client in the left lateral Trendelenburg position.
  3. 3Initiate 100% oxygen therapy via a non-rebreather face mask.
  4. 4Activate the facility's rapid response team and notify the healthcare provider.
  5. 5Obtain a full set of vital signs and initiate continuous cardiac monitoring.

Cevap

The correct sequence for managing a suspected central line air embolism is to first clamp the catheter, then position the client in left lateral Trendelenburg, administer 100% oxygen, activate the rapid response team, and finally monitor vital signs continuously.
The correct sequence prioritizes halting the injury at its source (clamping), followed immediately by mechanically preventing the complication from worsening (positioning). Once the immediate physical threats are mitigated, physiological support (oxygen) is provided, followed by summoning a higher level of care and maintaining ongoing assessment.

Adım Adım Çözüm

1
Identify the emergency as a suspected air embolism due to the open central line and sudden respiratory distress, then immediately clamp the catheter.
The entry point for atmospheric air is sealed.
Source control is always the absolute first step in preventing further injury from an environmental hazard or equipment failure.
2
Place the client on their left side with the head of the bed lowered (left lateral Trendelenburg).
The air bubble is mechanically directed away from the pulmonary outflow tract.
An air embolus in the pulmonary artery blocks blood flow to the lungs, causing acute right heart failure and death. This position traps the air in the right atrium/ventricle.
3
Administer maximum supplemental oxygen.
The client receives high concentrations of oxygen.
Oxygen relieves the resulting ischemia and creates a concentration gradient that promotes the absorption of nitrogen, which makes up the majority of the air embolus.
4
Call for emergency assistance.
Advanced medical support is mobilized.
The client requires critical care evaluation and potentially advanced interventions (such as aspiration of the embolus) that require a specialized team.
5
Assess the client's physiological status.
Baseline and ongoing data are collected.
Continuous monitoring is required to detect cardiopulmonary collapse and evaluate the efficacy of the immediate interventions.

Anahtar Kavram

Emergency management of a central venous catheter air embolism to prevent cardiopulmonary collapse.
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru