# A nurse is caring for a client receiving hemodialysis when the client suddenly develops chest pain, dyspnea, and restlessness. The client's blood pressure drops from 140/90 mmHg to 90/60 mmHg, and heart rate increases from 78 bpm to 120 bpm. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541422 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client receiving hemodialysis when the client suddenly develops chest pain, dyspnea, and restlessness. The client's blood pressure drops from 140/90 mmHg to 90/60 mmHg, and heart rate increases from 78 bpm to 120 bpm. What is the nurse's priority action? ## 보기 1. Administer oxygen via nasal cannula at 2 L/min 2. Notify the healthcare provider immediately 3. Stop the dialysis treatment and clamp the vascular access **✔ 정답** 4. Place the client in Trendelenburg position **정답: 3** ## 해설 Air embolism during hemodialysis requires immediate cessation of dialysis and clamping of vascular access to prevent further air entry. Other interventions like oxygen and positioning are secondary after stopping the source. ## 심화 해설 Understanding the Clinical Emergency The sudden onset of chest pain, dyspnea, and hypotension in a client undergoing hemodialysis, coupled with a machine alarm for air detection, signals a venous air embolism (VAE). This is a rare but life-threatening iatrogenic complication where air enters the venous circulation, travels to the right ventricle, and obstructs pulmonary blood flow, leading to cardiovascular collapse. The pathoanatomy involves not just a physical "air lock" in the pulmonary artery, but also a profound thromboinflammatory response where the air-blood interface activates platelets, complement, and leukocytes, causing endotheliopathy and worsening the obstruction [3]. In the context of hemodialysis, air can be introduced through disconnected lines, faulty seals, or during catheter manipulation [1,2]. Analyzing the Answer Choices The correct immediate priority is to clamp the venous line and place the client in the Trendelenburg position. This two-step intervention directly addresses the source and the pathophysiology of the air embolus. The other options are incorrect because they fail to stop the air entry or use positioning that could worsen the client's condition. Why the Correct Action is Priority The nurse's immediate priority is to prevent further air entry and to trap the existing air to minimize cardiopulmonary damage. Clamping the venous line immediately stops the influx of air, which is the source of the problem. Simultaneously, positioning the client in the Trendelenburg position (head down, feet up) and on their left side (left lateral decubitus, often combined as Durant's maneuver) serves a critical purpose. This position places the right ventricular outflow tract below the right ventricular cavity. Because air is buoyant, the embolized air will rise and become trapped in the apex of the right ventricle, away from the pulmonary artery. This maneuver can break the "air lock" and restore some forward blood flow, buying time for definitive management [2]. A recent case series on managing VAE during tunneled hemodialysis catheter placement highlighted that a practical combination of positional maneuvers and direct catheter-based aspiration was key to successful resuscitation, reinforcing that positioning is a foundational, life-saving first step [2]. Why the Other Options Are Incorrect - Option 1 (Continue dialysis while administering oxygen): This is dangerous because it fails to stop the ongoing entry of air, allowing the embolism to worsen. While high-flow 100% oxygen is an important supportive measure to reduce embolus size by creating a nitrogen gradient, it is not the immediate priority over stopping the air source. - Option 3 (Stop the dialysis machine and prepare for emergency intubation): Stopping the machine is necessary, but simply stopping it without clamping the line may not halt air entry if the system is not sealed. Furthermore, preparing for intubation is a secondary step. Positive pressure ventilation can actually worsen VAE by increasing intrathoracic pressure, which may force air from the right heart into the pulmonary artery or across a patent foramen ovale into the systemic circulation, potentially causing a cerebral air embolism or pneumocephalus, a devastating complication documented in hemodialysis patients [1]. - Option 4 (Increase the dialysis flow rate): This action is contraindicated as it would accelerate the delivery of air into the patient's circulation, rapidly worsening the hemodynamic instability.References (research sources) - [1]Cerebral air embolism presenting as acute pneumocephalus during hemodialysis via an arteriovenous fistula in a patient with end-stage renal disease: a case report.Case reportHakorimana F, Niyongira V, Mukwesi C, Kamana R, Rudakemwa E, Huluka DK. (2026) · DOI: 10.1186/s12882-026-05104-8 - [2]Management of Venous Air Embolism During Tunneled Hemodialysis Catheter Placement: Role of Targeted Aspiration and Patient Positioning.Research articleChandola S, Naranje P, Gamanagatti S. (2026) · DOI: 10.1111/hdi.70055 - [3]Iatrogenic air embolism: pathoanatomy, thromboinflammation, endotheliopathy, and therapies.Research articleMarsh PL, Moore EE, Moore HB, Bunch CM, Aboukhaled M, Condon SM, Al-Fadhl MD, Thomas SJ, Larson JR, Bower CW, Miller CB, Pearson ML, Twilling CL, Reser DW, Kim GS, Troyer BM, Yeager D, Thomas SG, Srikureja DP, Patel SS, Añón SL, Thomas AV, Miller JB, Van Ryn DE, Pamulapati SV, Zimmerman D, Wells B, Martin PL, Seder CW, Aversa JG, Greene RB, March RJ, Kwaan HC, Fulkerson DH, Vande Lune SA, Mollnes TE, Nielsen EW, Storm BS, Walsh MM. (2023) · DOI: 10.3389/fimmu.2023.1230049 ## 임상 시나리오 Clinical Practice Guide: Suspected Air Embolism During Hemodialysis The following immediate actions are critical when a patient on hemodialysis develops sudden chest pain, dyspnea, hypotension, and tachycardia, suggesting a venous air embolism. 1 **Stop the Dialysis Immediately** Turn off the blood pump. This halts the active forcing of air into the patient's venous circulation under pressure from the compromised circuit. 2 **Clamp the Vascular Access** Clamp the venous and arterial lines or the catheter hub. This physically occludes the direct conduit to the central circulation, preventing further air entrainment even after the pump is stopped. Do not disconnect the lines initially to avoid an open portal for air. 3 **Position the Patient** Place the patient in the **left lateral decubitus (Durant's maneuver)** and Trendelenburg position (head down) to trap air in the right atrium and prevent it from entering the pulmonary artery. Note: Trendelenburg alone is contraindicated as it may trap air in the right ventricle. 4 **Administer High-Flow Oxygen** Apply 100% oxygen via a non-rebreather mask. This helps reduce the size of the air embolus by promoting nitrogen washout and improves tissue oxygenation. 5 **Notify the Provider and Prepare for Advanced Support** Call the healthcare provider immediately after the initial life-saving measures. Anticipate the need for fluid resuscitation, vasopressors, and possible transfer to a critical care setting. **Key Safety Alert:** Air embolism is a life-threatening emergency. The priority is always to stop the source of air entry. Never hesitate to clamp the line if a breach in the circuit integrity is suspected. ## 핵심 개념 - **Venous Air Embolism** — A condition where air enters the venous circulation, travels to the right ventricle, and creates an air lock obstructing pulmonary blood flow, leading to cardiovascular collapse. - **Air Lock** — A mechanical obstruction in the right ventricle or pulmonary artery caused by a large air bubble, preventing effective blood flow and causing acute right heart failure. - **Hemodialysis Circuit** — The extracorporeal blood pathway including tubing and dialyzer; a compromised circuit can act as a direct conduit for air to enter the patient's bloodstream under pump pressure. - **Vascular Access Clamping** — The immediate physical occlusion of the dialysis catheter or needle hub to stop the entrainment of air into the central venous system. ## 같은 주제 문제 - [A nurse is assessing a patient who has just completed a hemodialysis session. 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