VATI Medical-Surgical Nursing Practice Exam

In the scenario where a central venous catheter (CVC) becomes disconnected and the client exhibits shortness of breath, the immediate priority for the nurse is to close the pinch clamp on the CVC. This action is vital to prevent air from entering the bloodstream, which can lead to an air embolism, a potentially life-threatening condition.

By closing the pinch clamp, the nurse effectively minimizes the risk of air entry through the catheter while addressing the client's respiratory distress. It stabilizes the situation and buys time to implement other critical interventions, such as administering oxygen or calling for assistance.

Addressing the disconnection first helps ensure that the client's airway and cardiovascular integrity are maintained before other actions, such as applying a sterile dressing to the site or providing supplemental oxygen, can be considered.