Wales, who underwent post-abdominal surgery, has a nasogastric tube.

The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions.

The client is not oriented to person, place, or time.

The nurse contacts the attending physician and STAT ABGs are ordered.

The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment?

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

A chylothorax refers to the accumulation of chyle, a milky, lymphatic fluid, in the pleural space. This typically results from disruption of the thoracic duct, often due to trauma or malignancy. The fluid's characteristic milky appearance is due to its high triglyceride content, not a pus-like consistency.

Choice B rationale

A pneumothorax is the presence of air in the pleural space, leading to lung collapse. It is characterized by respiratory distress and diminished breath sounds, not the presence of fluid with a pus-like appearance. This condition involves gas, not liquid, accumulation in the pleural cavity.

Choice C rationale

A hemothorax is the accumulation of blood in the pleural space, usually due to trauma or a ruptured blood vessel. The fluid would appear bloody, not pus-like. While blood can become infected, a primary hemothorax itself presents as serosanguineous or frank blood, differing from purulent exudate.

Choice D rationale

Empyema refers to the accumulation of pus in the pleural space, most commonly caused by bacterial infection. The pus-like appearance of the drained fluid is a direct indication of a significant inflammatory and infectious process, where leukocytes, necrotic debris, and microorganisms are present, forming purulent exudate.