A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a. Measure intake and output every 4 hours.
b. Apply oxygen by mask or nasal cannula. c.
Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler's position.
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler's position will not address the client's problem.
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