The nurse is reviewing labs for her adolescent client who is in the ICU. He had been receiving intravascular fluids until yesterday. She notices that the client has hypernatremia. Her next action should be to:
1. Assess the client for skin tenting.
2. Obtain a reading on the pulse oximeter.
3. Check the client's temperature.
4. Evaluate for edema.
1
Rationale: Assessing a client for skin turgor or "tenting" can be used to screen for the hydration status of a client. Although this may not be useful in older adults due to subcutaneous tissue loss and changes in skin elasticity related to aging, it may be a good indicator in an adolescent. Hypernatremia refers to elevated serum sodium levels and signals the loss of water from the extracellular fluid. The condition of hypernatremia does not impact the client's oxygenation status, temperature or result in edema.
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