A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included in the care plan of Mark for his patient?
A. Administering I.V. and oral fluids.
B. Clustering necessary activities throughout the day.
C. Assessing color, odor, and amount of sputum.
D. Monitoring serum albumin and total protein levels.
Correct Answer: A. Administering I.V. and oral fluids
The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs. Fluids are necessary to maintain hydration status. Determination of the type and amount of fluid to be replaced and infusion rates will vary depending on clinical status.
Option B: Clustering activities help with energy conservation and promote rest. Aid the patient if he or she is unable to eat without assistance, and encourage the family or SO to assist with feedings, as necessary. Dehydrated patients may be weak and unable to meet prescribed intake independently.
Option C: Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Assess skin turgor and oral mucous membranes for signs of dehydration. Signs of dehydration are also detected through the skin. Skin of elderly patients loses elasticity, hence skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.
Option D: Monitoring albumin and protein levels are appropriate for clients experiencing inadequate nutrition. Monitor and document hemodynamic status including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available in a hospital setting. These direct measurements serve as an optimal guide for therapy.
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