A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?
a. Inspection of oral mucosa
b. Recent dietary intake
c. Heart rate and rhythm
d. Percussion of abdomen
ANS: C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.
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What will be an ideal response?