The nurse is assessing the hydration status of the patient. Which action(s) demonstrates knowledge of proper assessment? (Select all that apply.)
a. Monitoring the patient's daily weight.
b. Assessing the patient's skin turgor on the back of the hand.
c. Checking the patient's blood glucose level four times a day.
d. Assessing for skin tenting on the patient's forehead.
e. Asking the patient if he is experiencing thirst.
A, D, E
The skin of the abdomen, forearm, sternum, forehead, and thigh can be "tented" as a test for skin turgor by gently pinching up a fold of skin and observing the delay in return to normal. Assess-ment of skin turgor is not reliable on the back of the hand. Weight and experiencing thirst can be indicators of hydration status, along with further assessment. The patient's blood glucose level is not an assessment parameter for hydration status.
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