A nurse is providing care for an 82-year-old patient who has a colostomy and was admitted 3 days ago with weakness, nausea, vomiting, and loose stools. To determine the effectiveness of care, which of the following actions should the nurse take first?
a. Check a pulse oximetry reading
b. Determine the creatinine clearance
c. Weigh the patient
d. Measure urine specific gravity
ANS: C
This patient is at risk for dehydration. Daily weight is the most reliable indicator of fluid loss or gain. Pulse oximetry reflects oxygenation status and is not related to hydration. Creatinine clearance is a measure of kidney function, and specific gravity is an indirect measure of fluid balance. Skin turgor, mucous membranes, and vital signs may be other helpful indicators related to dehydration.
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