# A client who had a right subclavian central venous catheter inserted 30 minutes ago suddenly develops dyspnea, sharp right-sided chest pain, and an oxygen saturation of 88% on room air. The nurse auscultates absent breath sounds over the right lung. Which action should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505808&lang=en  
> language: en  
> subject: Reduction of Risk Potential  
> category: ROR

## Question

A client who had a right subclavian central venous catheter inserted 30 minutes ago suddenly develops dyspnea, sharp right-sided chest pain, and an oxygen saturation of 88% on room air. The nurse auscultates absent breath sounds over the right lung. Which action should the nurse take first?

## Option

1. Obtain a stat portable chest x-ray to confirm catheter tip position.
2. Administer high-flow oxygen via a non-rebreather mask. **✔ Correct answer**
3. Reposition the client onto the left side with the head down.
4. Notify the healthcare provider of the assessment findings.

**Correct answer: 2**

## Explanation

The client is exhibiting signs of a pneumothorax, a potential complication of central venous catheter insertion. The priority is to address the hypoxemia by administering high-flow oxygen to improve oxygen saturation. Obtaining a chest x-ray is important but delays immediate respiratory support. Repositioning onto the left side with the head down is indicated for suspected air embolism, not pneumothorax. Notifying the healthcare provider is necessary but should occur after initiating oxygen therapy to stabilize the client.

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