A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Choice A: Evaluating chest expansion is the first action that the nurse should take, because it assesses the client's respiratory status and potential for pneumothorax, which is a life-threatening condition that can result from chest trauma. The nurse should compare the movement of both sides of the chest and listen for breath sounds.

Choice B: Checking pupillary response to light is an important action, but not the first one, because it assesses the client's neurological status and potential for brain injury. The nurse should observe the size, shape, and symmetry of the pupils and their reaction to light.

Choice C: Checking the client's response to questions about place and time is another important action, but not the first one, because it assesses the client's level of consciousness and orientation. The nurse should ask the client simple questions such as their name, date, and location.

Choice D: Assessing the capillary refill is a less important action, and not the first one, because it assesses the client's peripheral circulation and tissue perfusion. The nurse should press on the client's nail beds or fingertips and observe how quickly the color returns.

Choice A Reason: This is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.

Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.

Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and fluid to drain from the pleural space. They are usually covered by a dressing and may not be visible.

Choice D Reason: This is correct because movement of the trachea toward the unaffected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.