An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

Rationale:
A. Place in lateral Trendelenburg position: This position lowers the head below the heart, which can increase cerebral blood volume and further raise intracranial pressure. Clients with head injuries should instead be maintained in a neutral head position with the head of the bed elevated about 30 degrees to promote venous drainage.

B. Insert a second large bore IV catheter: The client’s neurological deterioration suggests possible intracranial bleeding or herniation. Inserting another IV line ensures rapid access for fluids, osmotic diuretics, or emergency medications if the client’s condition worsens.

C. Schedule a repeat CT scan: New-onset anisocoria (unequal pupils) and vomiting indicate potential brain swelling or expanding hematoma. An urgent repeat CT scan helps identify evolving intracranial pathology that may require surgical intervention.

D. Apply artificial tear drops to left eye: A dilated, nonreactive pupil may indicate cranial nerve III involvement, impairing eyelid closure and corneal protection. Artificial tears prevent corneal drying and injury while further neurological evaluation is conducted.

E. Repeat Glasgow coma assessment: Ongoing monitoring of the Glasgow Coma Scale allows for early detection of further neurological decline. Frequent reassessments help guide interventions and communicate changes promptly to the healthcare provider.

Rationale for Correct Choices

• Obstructed tracheostomy: The client presents with thick, green mucus and diminished breath sounds in the right lower lobe, suggesting mucus plugging within the tracheostomy tube that limits air movement. Obstruction commonly occurs in patients with inadequate humidification or ineffective suctioning, leading to impaired ventilation and secretion buildup.

• Traumatic iatrogenic pneumothorax: The right-sided diminished lung sounds and pleural effusion on imaging are consistent with complications often resulting from tracheostomy care or suctioning trauma. Iatrogenic pneumothorax occurs when airway instrumentation or pressure changes injure the pleura, allowing air into the pleural space and collapsing the lung.

Rationale for Incorrect Choices

• Primary spontaneous pneumothorax: This occurs without underlying lung disease, often in tall, thin young adults. It is inconsistent with this client’s medical history of cerebral palsy and chronic oxygen therapy.

• Displaced tracheostomy: A displaced tracheostomy would cause acute respiratory distress, abnormal tracheal sounds, or subcutaneous emphysema. None of these findings are present, and oxygenation appears stable at her baseline FiO₂.