An adult client and spouse are seen in an urgent care clinic. The client presents with a temperature of 102 °F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours
The nurse notes that the client's mucous membranes are pale and dry. Which action by the nurse is the most appropriate?
A) Ask the spouse for more information.
B) Assess for pedal edema.
C) Assess skin turgor.
D) Administer IV fluids.
Answer: C
A client who presents with hyperthermia, vomiting, diarrhea, and pale dry mucous membranes requires assessment for dehydration. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support that the client is dehydrated and requires further intervention. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. The nurse must further assess the client prior to administering IV fluids.
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