Today’s NCLEX-RN® question of the day focuses on a patient who is experiencing problems during the removal of a peripherally inserted central venous catheter. What is the first thing a nurse should do?
During the removal of a peripherally inserted central venous catheter, the client becomes short of breath and reports chest pain. Which action should the nurse implement first?
A. Place the client on their right side
B. Call the health care provider immediately
C. Administer oxygen by face mask
D. Administer the prescribed analgesicScroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
C. Administer oxygen by face mask
Rationale: Air embolism, which refers to the entry of air into a client’s circulatory system, is a potentially fatal complication during central line removal. It can present as chest pain, dyspnea, and hypotension. During catheter removal, the client should be instructed to do a Valsalva maneuver to prevent the entry of air into the circulatory system. Other ways to help prevent an air embolism is to remove the catheter during expiration. If an air embolism is suspected, oxygen should be administered and the client should be positioned on the left side in the Trendelenburg position.
Major Takeaway
When an air embolism is suspected, oxygen should be administered and the client should be positioned on the left side in Trendelenburg position.
Incorrect answer explanations
A. Place the client on their right side
Rationale: A client with a suspected air embolism should be placed on their left side in Trendelenburg position to try to prevent potential emboli from traveling through the right side of the heart and into the pulmonary artery.
B. Call the health care provider immediately
Rationale: Although contacting the health care provider is indicated, it is not the priority action.
D. Administer the prescribed analgesic
Rationale: Although the client is experiencing pain, administering an analgesic is not the priority action and could contribute to further respiratory distress.
Reference
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M. & Bucher, L. (2017). Medical-surgical nursing: Assessment and management of clinical problems (10th ed.). St. Louis, MO: Elsevier Mosby.
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