A nurse is assisting the doctor for central line insertion in the right jugular vein. During catheter insertion, the nurse observes that the patient is having shortness of breath, chest pain, low blood pressure, and respiratory distress. What would be the expected finding and priority nursing intervention?

1. A

   This is expected finding, continue the procedure

2. B

   Air embolism, place the client in side-lying position with head lower than the feet

3. C

   Pneumothorax, place the client in supine position

4. D

   Cardiac dysrhythmia, administer the oxygen via face mask

Appeared in: NORCET 5 mains

Explanation

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• The sudden onset of severe respiratory distress, chest pain, and hypotension during CVC insertion are hallmark signs of a venous air embolism.
• The priority nursing intervention for a suspected air embolism is to immediately place the patient on their left side with the head of the bed lowered (Trendelenburg position).
• This specific positioning, known as Durant's maneuver, is a critical, life-saving action designed to trap the air bubble in the right ventricle, preventing its entry into the pulmonary artery.
• This option correctly pairs a life-threatening emergency with its immediate, correct, and life-saving intervention.

Why Other Options Were Wrong

• Option A: The patient is experiencing signs of a life-threatening complication. These findings are never expected or normal.
• Option C: While pneumothorax is a possible diagnosis (and is shown in the image), the priority intervention for respiratory distress is to place the patient in a High-Fowler's position to facilitate lung expansion, not supine. A supine position can worsen breathing difficulties.
• Option D: Cardiac dysrhythmias can occur if the guidewire irritates the myocardium, but this typically presents as changes on the ECG monitor. The primary symptoms described (respiratory collapse and hypotension) are more indicative of a mechanical obstruction like an air embolus or a pneumothorax.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Complications of Central Venous Catheter Insertion in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Recognizing the signs of venous air embolism during CVC insertion is a critical nursing skill. Immediate intervention is required to prevent mortality.
• The nurse's priority actions are to clamp the catheter, administer 100% oxygen, and place the patient in the left lateral Trendelenburg position, then immediately call for help.
• What if? If the patient's primary symptom was only a new arrhythmia on the monitor without respiratory distress, the nurse's first action would be to have the provider pull back the guidewire, as it is likely irritating the heart.

How to Approach the Question

• First, identify the critical clinical event: a patient is acutely decompensating during a high-risk procedure (central line insertion).
• Analyze the cluster of symptoms: shortness of breath, chest pain, hypotension, and respiratory distress. Recognize these as signs of a major cardiopulmonary complication.
• Evaluate the options by pairing the diagnosis with the proposed intervention. The correct answer must have both a plausible diagnosis AND the correct priority intervention.
• Rule out option A because these are clearly abnormal, life-threatening signs.
• Compare options B and C. Both pneumothorax and air embolism are possible. However, the intervention for air embolism in option B (side-lying, head down) is the correct, specific, life-saving maneuver. The intervention for pneumothorax in option C (supine) is not the best practice for respiratory distress (High-Fowler's is).
• Select the option that represents the most accurate and critical life-saving action a nurse can take. The correct positioning for air embolism is a key piece of emergency nursing knowledge.

Concept Tested & Keywords

• Concept Tested: Complications of Central Venous Catheter Insertion
• Stem keywords: central line insertion, right jugular vein, shortness of breath, chest pain, low blood pressure, respiratory distress
• Lead-in keywords: expected finding, priority nursing intervention
• Clinical cues: Procedure: Central line insertion (a risk factor for both pneumothorax and air embolism).
• Clinical cues: Symptoms: Sudden onset of cardiopulmonary collapse (shortness of breath, chest pain, hypotension).

Question ID

QGHE2eEcJeohrzRgQ72GpM

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 2-4, 36-38