A nurse is caring for a client receiving intravenous nutritional therapy via a central catheter. The client suddenly reports difficulty breathing and is observed to have distended neck veins and cyanosis. What is the first action the nurse should take?
Stop the infusion, position the client on their left side with the head lowered, and administer oxygen.
Administer oxygen and encourage the client to take deep breaths while monitoring closely.
Encourage the client to lie flat and take deep breaths to improve their breathing symptoms.
Continue the infusion, notify the healthcare provider, and monitor the client for further changes.
The correct answer is to stop the infusion, place the client on their left side, and lower the head of the bed. This positioning helps prevent air from traveling to the pulmonary circulation by trapping the embolus in the right atrium, while halting the infusion prevents further complications. Administering oxygen is also essential to improve oxygenation in the presence of hypoxia. Simply notifying the healthcare provider or monitoring the client delays immediate life-saving actions. Encouraging deep breathing along with routine monitoring does not address the embolus, and administering oxygen without addressing the embolus positioning would be incomplete care.
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