Author Question: A nurse has been assigned to provide care for a patient who has class IV heart failure. Which ... (Read 26 times)

Ebrown · **on:** Jul 23, 2018

A nurse has been assigned to provide care for a patient who has class IV heart failure. Which nursing interventions are indicated?

1. Assist nursing support personnel with the patient's bed bath.
2. Accompany the patient on a walk to the courtyard.
3. Monitor that the patient's position is changed every 2 hours.
4. Take vital signs before and after physical therapy weight-bearing exercises.
5. Assist the patient with meals as indicated.

Question 2

The physician has prescribed phenytoin (Dilantin) for a patient with type 1 diabetes mellitus. What does the nurse include in the plan of care for this patient?

1. Plan to discuss with the physician the need to decrease the patient's insulin based on serum glucose levels.
2. Plan to discuss with the physician the need to increase the patient's insulin based on serum glucose levels.
3. Plan to assess the patient for petechiae, epistaxis, and hematuria.
4. Plan to institute safety precautions, as the patient is at risk for dizziness and ataxia.

josephsuarez · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

1,3,5
Rationale 1: This patient will most likely require a total bed bath.
Rationale 2: This patient is not likely to tolerate walking.
Rationale 3: This patient may not be able to initiate frequent moving in bed, so the nurse must intervene.
Rationale 4: The patient will not be able to participate in weight-bearing exercises.
Rationale 5: The patient may have difficulty feeding self, so monitoring and assistance are indicated.

Global Rationale: This patient will most likely require a total bed bath. This patient may not be able to initiate frequent moving in bed, so the nurse must intervene. The patient may have difficulty feeding self, so monitoring and assistance are indicated. This patient is not likely to tolerate walking. The patient will not be able to participate in weight-bearing exercises.

Answer to Question 2

2
Rationale 1: Phenytoin (Dilantin) can increase serum glucose levels, not decrease them.
Rationale 2: Phenytoin (Dilantin) can increase serum glucose levels, and the patient may need additional insulin.
Rationale 3: All patients receiving phenytoin (Dilantin) are at risk for petechiae, epistaxis, and hematuria; this is not specific to the patient with type 1 diabetes mellitus.
Rationale 4: All patients receiving phenytoin (Dilantin) are at risk for dizziness and ataxia; this is not specific to the patient with type 1 diabetes mellitus.
Global Rationale: Phenytoin (Dilantin) can increase serum glucose levels, and the patient may need additional insulin. All patients receiving phenytoin (Dilantin) are at risk for dizziness and ataxia; this is not specific to the patient with type 1 diabetes mellitus. All patients receiving phenytoin (Dilantin) are at risk for petechiae, epistaxis, and hematuria; this is not specific to the patient with type 1 diabetes mellitus. Phenytoin (Dilantin) can increase serum glucose levels, not decrease them.