A nurse removes a client's central venous catheter from the subclavian site and applies an occlusive dressing. Immediately afterward, the client reports chest pain, becomes acutely anxious, and a churning sound is auscultated over the precordium. Oxygen saturation drops to 88%. Which action should the nurse take first?
- AAuscultate breath sounds bilaterally
- BAdminister 100% oxygen by non-rebreather mask
- CPosition the client on the left side in Trendelenburg's position
- DCall the rapid response team
Show answer & explanationAnswer & explanation
Correct answer: C. Position the client on the left side in Trendelenburg's position
These findings (chest pain, churning murmur, hypoxia, anxiety immediately after central line removal) indicate an air embolism. The immediate priority is to position the client in left lateral Trendelenburg's position, which traps air in the right atrium away from the pulmonary outflow tract, preventing it from traveling to the lungs. Oxygen and calling for help are important but secondary to positioning, which directly addresses the life-threatening mechanism.
Why the other options are wrong
- A. Auscultation does not address the immediate life-threatening cause.
- B. Oxygen should be applied but does not stop the air from moving into the pulmonary circulation.
- D. Calling for help is appropriate but should occur after or simultaneously with positioning, not instead of it.
Venous Air Embolism
Entry of air into the venous system, often during central line insertion or removal, causing a churning heart murmur, chest pain, and hypoxia.
- Occurs during central line insertion/removal if the site is not occluded
- Position: left lateral Trendelenburg's traps air in right atrium
- Classic sign: mill-wheel/churning murmur
- Prevent by having client perform Valsalva during catheter removal
Memory trick: 'Left side down, head down, air stays trapped in the drum (right atrium).'