The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPAP. While caring for this patient, the nurse's priority will be to:
1. Monitor the expiratory time to be sure that it always exceeds the inspiratory time.
2. Ensure that the mask does not fit too tightly on the patient's face to prevent skin breakdown.
3. Prepare for endotracheal intubation because BiPAP is used primarily to buy time for intubation.
4. Assess the patient for the development of gastric distention, nausea, and vomiting.
4
Rationale 1: This is not something that the nurse needs to monitor for the patient receiving BiPAP.
Rationale 2: Although important, this is not a priority for the nurse when caring for the patient receiving BiPAP.
Rationale 3: BiPAP provides end-expiratory pressure, further decreasing the work of breathing. It is not used primarily to buy time for intubation.
Rationale 4: The nurse must assess the patient for complications resulting from this delivery method to include gastric distention, nausea, vomiting, and aspiration.
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