Question

Match the nursing interventions with the appropriate rational for Daniel

Review client's medication Monitor intake and output

Assess skin turgor and oral mucous membranes

Assess for hypotension, dry skin and mucous membranes and delayed capillary refill.

Assess for hypotension, dry skin and mucous membranes and delayed capillary refill

Answer 1

Assess skin turgor and oral mucous membranes

Rationale: Dehydration exhibitions in accumulation to damage of skin tugor, longitudinal tongue channels, recessed eyes, dehydrated mucus membranes, upper body muscle faintness, speech trouble and confusion. Moderate dehydration: production of urine will be incomplete and color of urine will be murky yellow, spasms, stiff and/or sore joints, severe prickliness, exhaustion, severe headache.

Assess for hypotension, dry skin and mucous membranes and delayed capillary refill

Rationale: Lengthy capillary refill time and orthostatic hypotension are not reliable signs of mild to moderate hypovolemia, capillary refill time Increase in the Body Heat, Dizziness, Fainting or syncope, Nausea, Body malaise, Cold and clammy extremities, Reduced urine production, Deficiency of coordination.