Following the insertion of a central venous access device, the nurse notes a weak, thready pulse and decreased blood pressure. The patient complains of shortness of breath and palpitations. Which action will the nurse take first?
a. Place the patient on the left side.
b. Reassess vital signs.
c. Stop the infusion.
d. Verify placement of the device.
ANS: A
Signs and symptoms indicate an air embolism. The nurse's immediate action will be to place the patient onto his or her left side. The nurse has determined change in pulse and blood pressure already, and although it is appropriate to reassess, it is not the first action the nurse will take. There is no indication that anything is infusing into this venous access device. Verifying the placement of the device is not the first action the nurse would take.
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