The nurse is performing an assessment on a patient who has had nothing by mouth since the previous evening.Which manifestation related to the patient’s fluid restriction should be of concern to the nurse?
Dry mucous membranes
The nurse should be concerned if the patient is exhibiting signs of dehydration, such as decreased urine output, dark yellow urine, dry mouth, and dry or cool skin. Additionally, the nurse should assess for signs of hypovolemia, which is a decrease in blood volume. Signs of hypovolemia include low blood pressure, rapid pulse, and dizziness upon standing. It is important for the nurse to closely monitor the patient’s fluid status and report any concerning findings to the healthcare provider. The nurse should also encourage the patient to drink fluids as allowed to prevent dehydration.
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