Ati Lpn Med Surg Electrolyte Proctored Exam(Delaware College)
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?
Explanation & Rationale
A. Jugular vein distention is typically a sign of fluid overload or right-sided heart failure, not dehydration. B. Red mucous membranes are more commonly associated with inflammation or infection and are not a reliable indicator of dehydration. C. Elevated blood pressure may be related to hypertension but does not specifically indicate fluid deficit. D. Skin tenting, or decreased skin turgor, occurs when the skin remains elevated after being pinched due to loss of interstitial fluid, making it a classic and observable sign of dehydration, especially in older adults.
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