The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?*1 pointa. Client behavior that changes from anxious to lethargicb. Deep furrows on the surface of the tonguec. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinchedd. Urine output of 950 mL for the past 24 hours

A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?*1 pointa. Tenting of skin on the back of the handb. Increased urine osmolarityc. Weight loss of 10 poundsd. Pulse rate of 115 beats/min

Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?*1 pointa. The client has dry, scaly skin on bilateral upper and lower extremities.b. The client states that he gets up three or more times during the night to urinate.c. The client states that he feels lightheaded when he gets out of bed or stands up.d. The nurse observes tenting on the back of the hand when testing skin turgor.

After receiving change-of-shift report, which client does the RN assess first?*1 pointa. A client with nausea and vomiting who complains of abdominal crampsb. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirstc. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hgd. A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion?*1 pointa. Measuring intake and output every shiftb. Slowing the IV flow rate to 50 mL/hrc. Administering diuretic agents as prescribedd. Placing the client in Trendelenburg position

Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?*1 pointa. Measuring intake and output every four hoursb. Applying oxygen by mask or nasal cannulac. Increasing the IV flow rate to 250 mL/hrd. Placing the client in a high Fowler's position