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.
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.
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