The nurse is caring for a client with acute respiratory failure who has been placed on bi-level positive airway pressure (BIPAP) for adequate ventilation. The client complains of nausea and begins to vomit. The priority nursing intervention would be:

remove the BIPAP mask.

Assist the client to a side lying position.

administer ondansetron intravenously (IV).

notify the primary care provider.

Answer and Explanation

The Correct Answer is B

A. Remove the BIPAP mask:
While removing the BIPAP mask may seem like a reasonable action to take in response to vomiting, it is not the immediate priority. The most urgent issue in this scenario is preventing aspiration and maintaining the client’s airway. Removing the mask may be necessary later for resuscitation or further interventions, but the first priority is protecting the airway and preventing aspiration pneumonia, which is best done by positioning the client appropriately. BIPAP should only be removed if the client's airway cannot be maintained, or if there is a need for intubation or other advanced airway management.

B. Assist the client to a side-lying position: When a client on BIPAP (bi-level positive airway pressure) begins to vomit, the priority nursing intervention is to protect the airway and prevent aspiration. The side-lying position is the most effective way to prevent aspiration of vomit into the lungs, as it allows the contents to drain from the mouth and reduces the risk of airway obstruction. This position also ensures that the client’s airway remains open while minimizing the risk of choking or aspiration pneumonia. The side-lying position is crucial in managing nausea and vomiting in clients on non-invasive ventilation, like BIPAP.

C. Administer ondansetron intravenously (IV):
Ondansetron is an effective antiemetic and may be appropriate to administer if the client’s nausea continues. However, nausea and vomiting are secondary concerns in this situation compared to airway protection. The first priority is to position the client to prevent aspiration of vomit. Once the client is in a safe position, ondansetron may be administered to address the nausea and prevent further vomiting, but this does not address the immediate airway risk.

D. Notify the primary care provider:
While notifying the healthcare provider may be necessary at some point, the priority nursing intervention is to manage the immediate concern of the client vomiting while on BIPAP. The primary concern at this point is protecting the airway and preventing aspiration. The healthcare provider may need to be informed about the situation, but the nurse must first ensure the client's safety through appropriate positioning.

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Correct Answer is A

Explanation

A. Sublingual nitroglycerin each day to prevent chest pain:
The statement about taking sublingual nitroglycerin daily is incorrect. Sublingual nitroglycerin is prescribed as needed for acute chest pain (angina) or for relieving chest discomfort associated with myocardial infarction (MI). It is not intended for daily use as a preventive measure. The client should be educated to use sublingual nitroglycerin only when experiencing chest pain, and if the pain persists or worsens, they should seek immediate medical help. Daily or routine use of nitroglycerin should be avoided unless specifically instructed by a healthcare provider. The client should also be educated about other preventive measures like long-acting nitrates if needed for chest pain prevention.

Explanation of other options:

B. Clopidogrel to prevent clots from forming:
This statement is correct. Clopidogrel (Plavix) is an antiplatelet medication commonly prescribed after a myocardial infarction to help prevent the formation of blood clots, which can reduce the risk of future cardiovascular events such as stroke or further heart attacks. It works by inhibiting platelets from clumping together, which is crucial in the post-MI period.

C. Atorvastatin at bedtime to reduce my cholesterol levels:
This statement is correct. Atorvastatin is a statin medication that is used to lower cholesterol levels, particularly LDL cholesterol (the "bad" cholesterol), which contributes to atherosclerosis and increases the risk of further heart problems. Statins are often prescribed after a myocardial infarction to help reduce the risk of future events. Taking atorvastatin at bedtime is also a common recommendation because cholesterol synthesis is higher during the night.

D. Metoprolol to decrease my heart's need for oxygen:
This statement is correct. Metoprolol is a beta-blocker that reduces the heart rate and blood pressure, which in turn lowers the heart's oxygen demand. After a myocardial infarction, beta-blockers like metoprolol are commonly prescribed to prevent further heart damage, reduce ischemia, and decrease the likelihood of arrhythmias. They help in the management of heart failure as well by improving the heart's efficiency.

A. decrease in heart rate. B. relief of chest pain. C. decrease in cardiac dysrhythmias. D. decrease in blood pressure.

Correct Answer is B

Explanation

A. Decrease in heart rate: While nitroglycerin can sometimes cause reflex tachycardia (an increase in heart rate) as a compensatory mechanism in response to a decrease in blood pressure, its primary effect is on reducing myocardial oxygen demand through vasodilation. Although heart rate may decrease in some situations due to improved perfusion or as a secondary response to pain relief, a decrease in heart rate is not the most reliable or immediate indicator of effectiveness in this context. The relief of chest pain is a more direct measure of the drug's impact.

B. Relief of chest pain: Nitroglycerin works by dilating blood vessels, which reduces myocardial oxygen demand and improves blood flow to the heart, particularly in cases of acute myocardial infarction (MI). The primary therapeutic goal is to relieve chest pain (angina) and reduce the workload of the heart. Monitoring for relief of chest pain is the most direct and important indicator of the medication's effectiveness. If the chest pain decreases or resolves, it suggests that the medication is helping to alleviate the ischemia caused by the MI.

C. Decrease in cardiac dysrhythmias: Nitroglycerin is not primarily used to treat dysrhythmias, although improved perfusion and reduced myocardial oxygen demand may indirectly reduce the occurrence of dysrhythmias in some cases. However, a decrease in dysrhythmias is not a primary goal of nitroglycerin therapy, and the nurse should not primarily monitor for this outcome. Any dysrhythmias should be managed with other specific interventions if needed.

D. Decrease in blood pressure: Nitroglycerin's vasodilatory effect does lead to a reduction in blood pressure, particularly in patients with high blood pressure or in the context of a myocardial infarction. However, excessive hypotension can be dangerous and may lead to inadequate perfusion of vital organs. The nurse must monitor blood pressure closely to avoid hypotension, but a decrease in blood pressure is not the main goal of therapy. The primary objective is to relieve the chest pain associated with the MI. If blood pressure drops too low, it may indicate a need to adjust the dose or discontinue the nitroglycerin.

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The nurse is caring for a client with acute respiratory failure who has been placed on bi-level positive airway pressure (BIPAP) for adequate ventilation. The client complains of nausea and begins to vomit. The priority nursing intervention would be:

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Naxlex Comprehensive Predictor Exams

The nurse prepares discharge instructions for the client diagnosed with a myocardial infarction. Which client statement indicates a need for further education? "I will take:

Correct Answer is A

Explanation

The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

Correct Answer is B

Explanation

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