While performing an integumentary assessment on a 72-year-old male client, the nurse notes the presence of tenting. Which of the following actions is indicated by the nurse first?
1. The nurse will need to notify the healthcare provider.
2. The rate of the intravenous infusion will need to be increased to combat dehydration.
3. A lung assessment will need to be performed.
4. No action is indicated.
4
Rationale 1: There is no need to notify the healthcare provider. The lack of skin turgor in an older client is a normal finding.
Rationale 2: It is beyond the nursing scope of practice for the nurse to independently alter the rate of the intravenous infusion of fluids.
Rationale 3: A lung assessment is not needed in relation to this client's clinical presentation.
Rationale 4: The lack of skin turgor in an older client is a normal finding. This is due to the reduction in elasticity of the skin.
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