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 B

Explanation

A. Tizanidine is a sleep aid and used to promote sleep along with melatonin:

This is incorrect. Tizanidine is not classified as a sleep aid. While muscle relaxants like tizanidine may cause drowsiness as a side effect, its primary purpose is to reduce muscle spasms rather than to promote sleep. Using it in combination with melatonin for sleep would not be appropriate unless specifically prescribed by a healthcare provider.

B. Tizanidine is a muscle relaxant medication used to reduce muscle spasms:

Tizanidine is a centrally acting muscle relaxant that is commonly used to treat muscle spasms and spasticity. In clients with amyotrophic lateral sclerosis (ALS), spasticity can be a significant symptom, leading to muscle stiffness and discomfort. Tizanidine helps by relaxing the muscles and alleviating the muscle tightness associated with ALS. It works by inhibiting nerve impulses that cause muscles to contract, thus reducing spasticity and improving mobility. This medication is not intended for sleep promotion or pain relief directly, but rather to manage muscle spasms.

C. Tizanidine is an antibiotic medication used to treat bacterial infections:

This is incorrect. Tizanidine is not an antibiotic and has no role in treating bacterial infections. It is a muscle relaxant used for managing spasticity, not an antimicrobial drug.

D. Tizanidine is an opiate and is used to relieve severe pain:

This is incorrect. Tizanidine is not an opiate and does not belong to the class of opioids. It does not have the pain-relieving effects of opioid analgesics. While it may provide some relief from muscle discomfort, it is not used to treat severe pain in the way opiates like morphine or oxycodone are. Tizanidine’s primary purpose is to address muscle spasticity, not pain management.

A. allowing undamaged areas in the lower part of the lungs to be ventilated." B. relieving pressure on the diaphragm and allowing expansion." C. decreasing pressure to the back of the rib cage." D. snifting fluid into the back area of the lungs.'

Correct Answer is A

Explanation

A. Allowing undamaged areas in the lower part of the lungs to be ventilated: The prone position is commonly used in patients with acute respiratory distress syndrome (ARDS) to improve oxygenation and ventilation. In ARDS, the lung tissue is often damaged, particularly in the dorsal (back) regions of the lungs, due to gravity and ventilation-perfusion mismatch. By placing the patient in the prone position, gravity helps redistribute the blood flow and improve ventilation to the posterior (lower) parts of the lungs, which are typically under-ventilated in the supine position. This positioning allows healthier or less-damaged areas of the lungs to receive better airflow, improving overall oxygenation.

B. Relieving pressure on the diaphragm and allowing expansion: While the prone position does shift pressure away from certain areas, its primary benefit is not related to relieving pressure on the diaphragm. The diaphragm, while somewhat affected by body position, is not the key structure being targeted for ventilation improvement. The main goal of prone positioning is to improve lung aeration in areas affected by ARDS, not directly to relieve diaphragm pressure.

C. Decreasing pressure to the back of the rib cage: The prone position does not specifically target reducing pressure to the back of the rib cage. Although it changes how pressure is distributed across the body, the main goal is to facilitate better ventilation and perfusion to the posterior lung regions, not necessarily to reduce pressure on the rib cage itself.

D. Sniffing fluid into the back area of the lungs: This option is unclear and not accurate. The prone position does not "sniff" fluid into the lungs; rather, it helps to redistribute fluid and improve the ventilation of the lung areas that are less affected by edema or inflammation in ARDS. The goal is to improve the ventilation/perfusion ratio and prevent further collapse of lung tissue.

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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 is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client was given a medical prescription for tizanidine. What information would the nurse provide regarding this medication? Tizanidine is

Correct Answer is B

Explanation

A client with a medical diagnosis of acute respiratory distress syndrome (ARDS) is being placed in the prone position. The nurse explains to family members that, "This will help improve ventilation by:

Correct Answer is A

Explanation

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