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) Fluid bolus and IV heparin:
A fluid bolus and IV heparin may be used in certain cardiovascular conditions, such as hypotension or in the setting of acute coronary syndrome (ACS) to prevent clot formation. However, in this case, the client is experiencing chest pain with ST segment elevations, a sign of ongoing ischemia, which suggests that the problem may be related to inadequate blood flow to the heart. Fluid boluses could exacerbate the condition if the heart's function is compromised, and IV heparin alone would not address the root cause of the ischemia. Hence, this is not the most appropriate intervention at this time.

B) A medical prescription for a stat chest x-ray:
A chest x-ray would not be immediately indicated in this scenario. The client's symptoms of chest pain, diaphoresis, and ST segment elevations on the ECG are indicative of myocardial ischemia or infarction, not a respiratory or structural lung issue that would be visualized on an x-ray. The priority here is to address the myocardial ischemia, which could be due to a clot or reocclusion in the coronary artery. A stat chest x-ray would not address the underlying cardiac issue, so this is not the best choice.

C) Coronary artery bypass (CABG) surgery if there is no improvement in 12 hours:
While CABG is an option for clients with severe coronary artery disease, it is generally considered when PCI is not successful or when there are multiple blockages that cannot be stented. In this situation, since the client has just undergone PCI and is now experiencing signs of reocclusion (e.g., chest pain, ST segment elevations), a repeat PCI with thrombectomy or angioplasty is more appropriate and urgent. Waiting 12 hours would delay treatment and risk further myocardial damage. CABG would not be the first intervention after a failed PCI within hours of the procedure.

D) Repeat PCI with thrombectomy or angioplasty:
This is the most appropriate intervention. The client's symptoms (chest pain, diaphoresis, and ST segment elevations) are suggestive of reocclusion of the stented artery, a complication that can occur after PCI. Reocclusion can cause further myocardial ischemia and infarction. A repeat PCI with thrombectomy or angioplasty would aim to reopen the blocked artery and restore blood flow to the myocardium, which is the immediate priority in this situation. This intervention can help resolve the ischemia and prevent further damage to the heart muscle.

A. "How long have you had the pain?" B. "Do you have a history of coronary artery disease?" C. "How would you describe your pain?" D. "What were you doing when the pain began?" E. "Can you rate your pain on a 0-10 scale?"

Correct Answer is ["A","C","D","E"]

Explanation

A. "How long have you had the pain?"
Asking about the duration of the pain is crucial in assessing a myocardial infarction (MI). The length of time the pain has been occurring can help the nurse determine if the pain is acute or has been ongoing. For instance, chest pain lasting more than 20 minutes or worsening in intensity could indicate an MI. Knowing the timing of the pain also helps establish whether it may be related to acute coronary syndrome (ACS), which requires immediate intervention.

B. "Do you have a history of coronary artery disease?"
While it’s important to understand the patient’s medical history, this question is more secondary during the initial assessment of a client with chest pain. This information is valuable for understanding the risk of cardiovascular events, but it is not the immediate focus when assessing the current pain. The nurse should prioritize questions that address the current symptoms and the characteristics of the pain first.

C. "How would you describe your pain?"
This question is essential to help differentiate the chest pain associated with a myocardial infarction from other causes, such as musculoskeletal pain or gastrointestinal issues. MI pain is typically described as a crushing, pressure-like, or squeezing sensation. Identifying the quality of the pain helps establish whether it’s consistent with a cardiac event. Understanding the description of the pain also provides information about the intensity and potential for myocardial damage.

D. "What were you doing when the pain began?"
This is an important question because activity-related chest pain can help determine the potential cause of the pain. Pain associated with physical exertion or emotional stress may point to an MI or angina. On the other hand, pain unrelated to activity might suggest other causes such as gastrointestinal issues or musculoskeletal pain. Inquiring about the onset of the pain can also provide insight into whether it is associated with physical strain or acute coronary syndrome.

E. "Can you rate your pain on a 0-10 scale?"
Pain assessment using a numeric pain scale (0-10) helps the nurse gauge the severity of the pain and track changes over time. It’s important for determining whether the pain is severe enough to be consistent with an acute myocardial infarction or if it might resolve on its own. This information is vital in deciding the urgency of interventions and treatment decisions.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

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