The physician is preparing to remove a central line. The nurse should tell the client to?

DHS 2018 shift 1st

Medical & Surgical Nursing

Medium

Appeared in: DHS 2018 shift 1st

Explanation

Instructing the client to take a deep breath and hold it prompts them to perform the Valsalva maneuver.
The Valsalva maneuver significantly increases intrathoracic (chest cavity) pressure, making it higher than the outside atmospheric pressure.
This positive pressure gradient prevents air from being sucked into the large vein when the catheter is withdrawn, which is the primary method to prevent a life-threatening air embolism.

Option A: The inspiratory phase of normal breathing creates negative intrathoracic pressure relative to the atmosphere, which can draw air into the open vessel, causing an air embolism.
Option B: Taking a slow, deep breath creates an even greater negative pressure inside the chest compared to normal breathing. This substantially increases the risk of a large air embolism.
Option D: Rapid breathing (hyperventilation) involves multiple, rapid inspiratory cycles. This creates repeated opportunities for air to enter the vein and causes unpredictable pressure changes, increasing the overall risk.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prevention of air embolism during central venous catheter removal to guide bedside assessment, documentation, and the next nursing action.
Preventing an air embolism is a critical, non-negotiable patient safety responsibility for the nurse during central line removal. An air embolism can obstruct pulmonary vessels, leading to cardiovascular collapse and death.
The nurse must also ensure an occlusive dressing (e.g., petroleum gauze) is applied immediately after removal and pressure is held to seal the site completely.
What if? If the patient is intubated, unconscious, or otherwise unable to follow commands, the nurse should coordinate with the provider to withdraw the catheter during the peak of the expiratory phase of the ventilator cycle, when intrathoracic pressure is highest.

How to Approach the Question

Identify the clinical procedure: Removal of a central line.
Recall the most serious, immediate complication associated with this procedure: Air embolism.
Understand the underlying pathophysiology: Air can be sucked into the venous system because of the negative pressure created in the chest during inspiration.
Determine the preventive action: The goal is to reverse this pressure gradient by making the pressure inside the chest higher than the outside air pressure.
Evaluate the options: 'Taking a deep breath and holding it' (the Valsalva maneuver) is the standard technique to increase intrathoracic pressure. All other breathing patterns involve an inspiratory phase that creates risk.

Concept Tested & Keywords

Concept Tested: Prevention of air embolism during central venous catheter removal.
Stem keywords: central line, remove, nurse, client
Lead-in keywords: should tell the client to

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 2-4

E6 Nursing Fundamentals Taylor p. 724-726