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 D

Explanation

A. Serum potassium of 5.2 mEq/L: A potassium level of 5.2 mEq/L is slightly elevated but is still within a potentially acceptable range (normal is 3.5-5.3 mEq/L). While elevated potassium can be a concern, particularly in the context of an MI or with certain medications (like potassium-sparing diuretics), this level is not critically high. The nurse should monitor the potassium levels, but this is not an urgent finding requiring immediate reporting unless it increases further or is accompanied by significant symptoms (such as arrhythmias).

B. T wave depression on electrocardiogram (ECG): T wave depression can be a sign of ischemia or injury, which is common in the setting of an acute myocardial infarction. However, T wave changes are expected in this context and do not indicate an immediate emergency. The nurse should continue to monitor the ECG for any progression or worsening of ischemic changes but should prioritize concerns such as hypotension or worsening clinical status over this finding.

C. Heart rate of 90 beats per minute: A heart rate of 90 beats per minute is within normal limits (60-100 beats per minute), especially in the early stages of an MI. Nitroglycerin may cause a reflex tachycardia as a compensatory response to the decreased blood pressure, but a heart rate of 90 bpm is not an alarming finding. The nurse should continue to monitor the heart rate, but it is not the most pressing concern compared to hypotension. 4o mini

D. Blood pressure of 90/50: A blood pressure of 90/50 mmHg is significantly low and could indicate that the client is experiencing hypotension, which is a known side effect of nitroglycerin infusion. Nitroglycerin causes vasodilation, which can reduce blood pressure, especially in clients who are already at risk due to an acute myocardial infarction (MI). Low blood pressure can compromise perfusion to vital organs, including the heart, brain, and kidneys, and may lead to shock if not corrected promptly. This finding should be reported immediately to the healthcare provider, as it may require adjustment of the nitroglycerin dosage or discontinuation of the infusion.

A. Resume smoking initially to help manage stress and anxiety. B. Consume a high-fat diet to promote weight gain and energy. C. Avoid physical activity and rest as much as possible. D. Continue taking all prescribed medications as directed. E. "Can you rate your pain on a 0-10 scale?"

Correct Answer is D

Explanation

A. Resume smoking initially to help manage stress and anxiety:
Smoking is a significant risk factor for cardiovascular disease and can worsen the prognosis after coronary artery bypass graft (CABG) surgery. Smoking increases the risk of coronary artery disease and impairs healing after surgery. Therefore, advising the client to resume smoking, even temporarily, is unsafe and completely contrary to health recommendations for post-CABG care. Smoking cessation should be emphasized as a key part of the recovery process.

B. Consume a high-fat diet to promote weight gain and energy:
A high-fat diet is not recommended for individuals with coronary artery disease, especially after CABG surgery. Consuming a diet high in saturated fats and cholesterol can lead to further plaque buildup in the coronary arteries, increasing the risk of atherosclerosis and cardiac events. After CABG, patients are typically encouraged to follow a heart-healthy diet that is low in saturated fat, high in fiber, and rich in fruits, vegetables, and lean proteins to support overall heart health and recovery.

C. Avoid physical activity and rest as much as possible:
While rest is essential immediately following surgery, complete avoidance of physical activity is not advisable long-term. In fact, early and gradual physical activity is a key component of rehabilitation after CABG surgery. A sedentary lifestyle can increase the risk of complications such as blood clots, muscle weakness, and weight gain, while physical activity helps improve circulation, heart function, and overall recovery. The nurse should encourage the client to gradually resume physical activity according to the guidance of their healthcare provider, often starting with light walking and progressing as tolerated.

D. Continue taking all prescribed medications as directed: Following coronary artery bypass graft (CABG) surgery, it is essential for the client to continue taking all prescribed medications, including antiplatelets, statins, beta-blockers, and any other medications ordered by the healthcare provider. These medications play a critical role in preventing blood clots, controlling blood pressure, reducing cholesterol levels, and preventing future cardiac events. Stopping or altering medications without consulting a healthcare provider could increase the risk of complications or recurrent cardiac events.

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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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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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