A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

A. View the rhythm in another chest lead. While verifying the rhythm in another lead may help confirm the accuracy of the monitor, it does not address the immediate absence of a pulse and respirations. The client is in pulseless electrical activity (PEA), which requires immediate intervention rather than rhythm verification.
B. Begin chest compressions at a rate of 120 times a minute. The client has no palpable carotid pulse and no spontaneous respirations despite a sinus rhythm on the monitor, indicating pulseless electrical activity (PEA). PEA is a form of cardiac arrest where the heart shows electrical activity but fails to generate effective circulation. Immediate high-quality chest compressions are essential to maintain perfusion while addressing the underlying cause, such as hypovolemia or tension pneumothorax.
C. Auscultate all chest fields for muffled lung sounds. While assessing for muffled lung sounds may help detect conditions such as tension pneumothorax or hemothorax, it should not delay the initiation of CPR. Once compressions are started, the underlying cause of PEA can be investigated.
D. Observe for swelling at the fracture site. Swelling at the fracture site may indicate bleeding or compartment syndrome, but assessing the fracture should not take priority over initiating CPR. If hemorrhage is suspected as a cause of PEA, rapid fluid resuscitation should be initiated after starting chest compressions.

A. Apply high-flow oxygen by face mask. The client is in respiratory distress with absent breath sounds over the left lung field, which is highly suggestive of a pneumothorax or hemothorax. High-flow oxygen helps improve oxygenation while preparing for definitive intervention. In cases of tension pneumothorax, oxygen can help reduce hypoxia until a chest tube or needle decompression is performed.
B. Obtain a chest tube insertion kit. Absent breath sounds on one side following chest trauma strongly suggest a pneumothorax or hemothorax, requiring immediate chest tube placement to re-expand the lung and restore normal ventilation. The nurse should ensure that the equipment for thoracostomy (chest tube insertion) is readily available for the healthcare provider.
C. Withhold narcotic pain medication. Pain control is important in trauma patients, as uncontrolled pain can lead to shallow breathing, atelectasis, and respiratory complications. Narcotics should be used cautiously in clients with respiratory distress, but they are not contraindicated if given at appropriate doses with close monitoring.
D. Elevate the head of the bed 45 degrees. Clients with respiratory distress should be positioned with the head of the bed elevated to improve lung expansion. However, in a suspected pneumothorax, the priority is oxygenation and chest tube insertion. If there is hemodynamic instability, the client may require a flat or semi-Fowler’s position instead.
E. Place client in Trendelenburg position. The Trendelenburg position (head down, feet up) is not appropriate in chest trauma patients. This position can increase intra-abdominal pressure, worsen breathing difficulty, and impair lung expansion. It is typically avoided in clients with respiratory distress or suspected pneumothorax.