Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 1==
A registered nurse is changing the injection cap on a client's tunneled central venous catheter when the client suddenly becomes dyspneic, hypotensive, and confused. Which action should the nurse take '''first'''?
# Administer 100 percent oxygen by nonrebreather mask.
# Clamp the catheter and place the client in the left lateral Trendelenburg position.
# Obtain a stat set of vital signs and a 12-lead electrocardiogram.
# Notify the rapid response team and the provider.

'''Answer:''' 2 (B). Clamp the catheter and place the client in the left lateral Trendelenburg position.

''Rationale:'' The presentation during an open central line manipulation is classic venous air embolism. Clamping stops further air entry, and left lateral Trendelenburg, the Durant maneuver, traps air in the apex of the right ventricle so it does not enter the pulmonary outflow tract. Oxygen in option 1 is the correct '''second''' action and helps reabsorb nitrogen, but it does not stop the ongoing air entry. Option 3 delays treatment for data collection. Option 4 is necessary but follows the immediate physical intervention the nurse can perform right now.