A 58-year-old male patient with a history of hypertension and type 2 diabetes mellitus is admitted to the medical-surgical unit with a diagnosis of left-sided congestive heart failure (CHF). He is experiencing dyspnea, orthopnea, and bilateral ankle edema. His current medications include Metformin, Lisinopril, and Furosemide. Upon assessment, the nurse notes an S3 heart sound, jugular venous distention, and crackles halfway up both lung fields. The patient's blood pressure is 158/92 mmHg, heart rate is 102 bpm, respiratory rate is 22 breaths/min, and oxygen saturation is 89% on room air. Which of the following nursing interventions should be prioritized? A) Increase the rate of the intravenous (IV) Furosemide infusion. B) Assist the patient to a high Fowler’s position and administer supplemental oxygen. C) Initiate a sliding scale insulin protocol. D) Increase Lisinopril dosage as per sliding scale.
A 58-year-old male patient with a history of hypertension and type 2 diabetes mellitus is admitted to the medical-surgical unit with a diagnosis of left-sided congestive heart failure (CHF). He is experiencing dyspnea, orthopnea, and bilateral ankle edema. His current medications include Metformin, Lisinopril, and Furosemide. Upon assessment, the nurse notes an S3 heart sound, jugular venous distention, and crackles halfway up both lung fields. The patient's blood pressure is 158/92 mmHg, heart rate is 102 bpm, respiratory rate is 22 breaths/min, and oxygen saturation is 89% on room air. Which of the following nursing interventions should be prioritized? A) Increase the rate of the intravenous (IV) Furosemide infusion. B) Assist the patient to a high Fowler’s position and administer supplemental oxygen. C) Initiate a sliding scale insulin protocol. D) Increase Lisinopril dosage as per sliding scale.
Chapter9: The Medication Order
Section: Chapter Questions
Problem 25RQ
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A 58-year-old male patient with a history of hypertension and type 2 diabetes mellitus is admitted to the medical-surgical unit with a diagnosis of left-sided congestive heart failure (CHF). He is experiencing dyspnea, orthopnea, and bilateral ankle edema. His current medications include Metformin, Lisinopril, and Furosemide.
Upon assessment, the nurse notes an S3 heart sound, jugular venous distention, and crackles halfway up both lung fields. The patient's blood pressure is 158/92 mmHg, heart rate is 102 bpm, respiratory rate is 22 breaths/min, and oxygen saturation is 89% on room air.
Which of the following nursing interventions should be prioritized?
A) Increase the rate of the intravenous (IV) Furosemide infusion.
B) Assist the patient to a high Fowler’s position and administer supplemental oxygen.
C) Initiate a sliding scale insulin protocol.
D) Increase Lisinopril dosage as per sliding scale.
Upon assessment, the nurse notes an S3 heart sound, jugular venous distention, and crackles halfway up both lung fields. The patient's blood pressure is 158/92 mmHg, heart rate is 102 bpm, respiratory rate is 22 breaths/min, and oxygen saturation is 89% on room air.
Which of the following nursing interventions should be prioritized?
A) Increase the rate of the intravenous (IV) Furosemide infusion.
B) Assist the patient to a high Fowler’s position and administer supplemental oxygen.
C) Initiate a sliding scale insulin protocol.
D) Increase Lisinopril dosage as per sliding scale.
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