The nurse is changing the intravenous tubing on a client's central venous catheter. During the procedure, the client suddenly gasps for air, grasps their chest, and becomes cyanotic. Arrange the following nursing actions in the correct priority sequence.
- 1Clamp the central venous catheter.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Notify the rapid response team and the healthcare provider.
- 5Monitor the client's vital signs and respiratory status continuously.
Cevap
The correct sequence is to first clamp the central venous catheter, then place the client in the left lateral Trendelenburg position, administer 100% oxygen via a non-rebreather mask, notify the rapid response team and healthcare provider, and finally monitor vital signs and respiratory status continuously.
In the event of a suspected air embolism from a central venous catheter, the immediate priority is to stop further air entry by clamping the line. The next critical action is positioning the client in the left lateral Trendelenburg position, which traps the air in the apex of the right ventricle and prevents it from occluding the pulmonary circulation. Once the embolus is isolated, administering 100% oxygen helps treat hypoxia and promotes the resorption of the nitrogen gas bubble. After these immediate life-saving parameters are secured, the nurse must notify the rapid response team and healthcare provider, followed by continuous monitoring of the client's hemodynamic status.
Adım Adım Çözüm
Anahtar Kavram
Prioritization of care for a client experiencing an air embolism requires immediate mechanical interventions (clamping and positioning) before pharmacological or supportive measures.