Jennifer Lopez, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery.

The PACU RN had been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain.

The client's respiratory rate is now 7 per minute and demonstrates shallow breathing.

The patient does not respond to any stimuli.

The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaC02 70 mm Hg, and HCO3 24 mEq/L. What does this mean?

Choice A rationale

While establishing IV access and fluid replacement are crucial in trauma, they are secondary to ensuring cervical spine stabilization in a patient who is unresponsive after a head-on motor vehicle crash. Uncontrolled movement of an unstable cervical spine can lead to irreversible spinal cord injury, exacerbating neurological deficits or causing paralysis.

Choice B rationale

Monitoring pulse and blood pressure frequently is an important ongoing assessment in a trauma patient to identify shock or other systemic issues. However, in the immediate post-crash scenario with an unresponsive patient, the primary concern is preventing further neurological damage from potential spinal cord injury, making stabilization a higher priority.

Choice C rationale

Inserting a nasogastric tube for decompression might be necessary later in the management of a trauma patient to prevent aspiration or gastric distension. However, it is not the immediate priority action in an unresponsive patient following a head-on collision, where airway, breathing, circulation, and most importantly, cervical spine protection are paramount.

Choice D rationale

In an unresponsive client following a head-on motor vehicle crash, cervical spine injury must be presumed until ruled out. Any movement of the head or neck could further compromise the spinal cord, leading to permanent neurological deficits or even death. Therefore, keeping the neck stabilized using a cervical collar and backboard is the absolute priority to prevent further injury.

Choice A rationale

Obtaining informed consent is a fundamental ethical and legal requirement before any invasive medical procedure, including a bronchoscopy. This ensures patient autonomy, allowing them to make an educated decision based on understanding the procedure's risks, benefits, and alternatives. The patient's signature indicates their voluntary agreement after a thorough discussion with the healthcare provider, demonstrating adherence to patient rights.

Choice B rationale

Flumazenil is a benzodiazepine receptor antagonist used to reverse the sedative effects of benzodiazepines. While benzodiazepines like midazolam are commonly used for conscious sedation during bronchoscopy, flumazenil is generally not kept readily available for routine use. It is an emergency reversal agent reserved for severe respiratory depression or over-sedation.

Choice C rationale

Ensuring the client is NPO (nil per os) for at least 6 hours prior to a bronchoscopy is crucial to prevent aspiration. The procedure involves manipulating the airway, which can stimulate the gag reflex and potentially lead to regurgitation of gastric contents into the lungs, causing aspiration pneumonia or acute respiratory distress. Fasting significantly reduces this risk.

Choice D rationale

Continuous monitoring of heart rate and oxygen saturation via a bedside heart monitor and pulse oximeter is essential during and after a bronchoscopy. This allows for immediate detection of adverse events such as hypoxemia, arrhythmias, or respiratory depression, enabling prompt intervention. Constant vigilance ensures patient safety throughout the procedure.

Choice E rationale

Midazolam, a short-acting benzodiazepine, is commonly used for conscious sedation during bronchoscopy. Its anxiolytic, sedative, and amnestic properties help to reduce patient anxiety, promote comfort, and minimize recall of the procedure. Its rapid onset and short duration of action make it suitable for outpatient procedures.