Question

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement?

A. Administer a PRN antihypertensive prescription.
B. Provide the client with an additional blanket.
C. Encourage additional fluid intake.
D. Turn the client q2h.

Answer 1

The most important nursing action for the elderly male client based on the given symptoms is to encourage additional fluid intake.

Step-by-step explanation:

Based on the assessment findings of an immobile, elderly male client with a blood pressure of 138/60, temperature of 95.8° F, output of 100 ml of concentrated urine during the last hour, wet-sounding lung sounds, and increased respiratory secretions, the most important nursing action is to encourage additional fluid intake. This action addresses potential dehydration, as indicated by the concentrated urine, and may also help thin respiratory secretions. Ensuring adequate hydration is vital in such a clinical presentation to prevent further complications, such as urinary tract infections or respiratory issues.