The nurse has reviewed the Provider Prescriptions.

Exhibits

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale:

A. Remove the client's catheter: Removing the catheter could allow more air to enter the circulation and worsen the embolism. The priority is to prevent further air entry while stabilizing the client, not immediate removal of the line.

B. Prepare the client for chest tube insertion: Chest tubes are used for pneumothorax or pleural effusions, not for treating an air embolism. Immediate positioning and oxygen therapy are the primary interventions.

C. Place the client in a left-lateral Trendelenburg position: Positioning the client in the left-lateral Trendelenburg (head down, left side down) traps air in the right atrium and prevents it from entering the pulmonary circulation, reducing cardiovascular compromise. This is the recommended first intervention for a suspected air embolism.

D. Instruct the client to perform the Valsalva maneuver: Performing the Valsalva maneuver increases intrathoracic pressure and may temporarily help, but it is not the first priority. Proper positioning and immediate oxygen administration are more critical to prevent complications.

Rationale:

A. Prime the infusion tubing with 0.45% sodium chloride.: Blood products should never be primed with hypotonic solutions like 0.45% sodium chloride because it can cause hemolysis of the RBCs. Only 0.9% sodium chloride (normal saline) is safe for priming and flushing blood administration tubing.

B. Assess the client's lung sounds prior to the infusion.: Older adults are at increased risk for fluid overload during transfusions. Assessing lung sounds before starting the infusion provides a baseline and helps detect early signs of pulmonary edema or transfusion-associated circulatory overload.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type.: Performing a second verification with another nurse is a critical safety measure to prevent transfusion reactions. Confirming blood type and crossmatch ensures compatibility and patient safety.

D. Don sterile gloves to prepare the blood administration setup.: Sterile gloves are not required for blood administration. Standard clean technique with non-sterile gloves is sufficient to prevent infection, as the IV setup does not require sterility.

E. Infuse the blood over 4 hr.: Red blood cells should be infused within 4 hours to minimize the risk of bacterial growth and ensure product viability. Infusing too slowly can increase infection risk, and infusing too quickly can cause fluid overload, especially in older adults.