A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?

A. Observe vital signs sequences as a way of assessing for Cushing's triad. Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased intracranial pressure (ICP). While monitoring for it is important, early recognition and direct ICP monitoring are more effective in preventing deterioration.
B. Evaluate hourly urinary output. Mannitol is an osmotic diuretic that can cause significant diuresis, requiring close monitoring of urine output to prevent dehydration and electrolyte imbalances. However, assessing ICP is the priority because increased ICP can cause brain herniation, which is life-threatening.
C. Monitor arterial blood pressure. Dopamine is a vasopressor used to maintain cerebral perfusion pressure (CPP), which is crucial in head injury management. While blood pressure monitoring is essential, directly assessing ICP ensures that treatment is effective in preventing secondary brain injury.
D. Assess intracranial pressure following intracranial transducer placement. The highest priority is monitoring ICP immediately after placement to detect dangerous elevations that could lead to herniation. The intraventricular catheter provides real-time pressure readings, guiding interventions like mannitol administration and blood pressure control to optimize cerebral perfusion and prevent worsening neurological damage.

A. Obtain a chest x-ray to verify endotracheal tube location. A chest x-ray is the gold standard for confirming ETT placement, but it is not the first step. Immediate bedside assessment is needed to ensure the tube is correctly positioned before relying on imaging. If the tube is misplaced in the esophagus, waiting for an x-ray could delay necessary corrections.
B. Call the respiratory therapist (RT) to verify tube placement. The nurse should first perform a rapid bedside assessment before consulting the RT. While RTs assist in confirming placement, the nurse is responsible for the initial verification of breath sounds, chest rise, and end-tidal CO₂ (ETCO₂) readings. Any concerns should be addressed immediately.
C. Instill normal saline into the endotracheal tube for suctioning. Instilling saline before suctioning is not recommended, as it can promote aspiration, decrease oxygenation, and increase infection risk. The priority is confirming that the tube is properly placed before performing any interventions such as suctioning.
D. Auscultate for breath sounds bilaterally in all lung fields. The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.