A nurse is planning care for an older adult client who has moderate Alzheimer's disease. Which of the following interventions should the nurse implement in the client's plan of care?

Rationale:
A. Close the pinch clamp on the CVC: Clamping the catheter is important to stop further air entry, but placing the client in the proper position takes priority to trap the air and prevent it from reaching the pulmonary circulation.

B. Obtain a prescription for stat ABGs: ABGs may help assess respiratory compromise, but they are not the immediate action. This diagnostic step should follow emergency interventions that prevent further complications from an air embolism.

C. Place the client in left Trendelenburg position: This is the priority action because it helps trap any air in the right atrium and prevents it from entering the pulmonary arteries, reducing the risk of a fatal air embolism. Positioning the client correctly is a critical first step in managing suspected air embolism.

D. Check the tubing for placement of a locking adaptor: Verifying equipment setup is important for preventing future incidents, but it does not address the client’s current critical condition. Immediate positioning takes precedence.

Rationale:

• Troponin I level: An elevated troponin I level indicates myocardial cell injury and is a key diagnostic marker for MI. Even a value at the upper limit of normal (0.03 ng/mL) warrants concern, especially with accompanying symptoms.
• ECG result – sinus tachycardia: Sinus tachycardia is nonspecific but may occur in both MI and angina due to pain, anxiety, or sympathetic stimulation. However, more definitive MI-related changes like ST elevation or Q waves would provide clearer diagnostic value.
• Heart rate: A heart rate of 116/min is elevated and may represent the body’s response to pain, hypoxia, or stress. This can be seen in both angina and MI, though persistent or worsening tachycardia in MI may indicate hemodynamic instability.
• Heart palpitations: Palpitations are common during episodes of angina and are often due to increased sympathetic tone or transient arrhythmias. They are usually mild and resolve with rest or nitroglycerin in stable angina.
• Blood pressure: A blood pressure of 158/92 mm Hg indicates hypertension, a known trigger and risk factor for angina. Elevated BP increases myocardial oxygen demand, potentially precipitating chest pain in those with coronary artery disease.