Question

The nurse is providing care for an older adult client in an acute care setting and notices that the client's intake and output are both low. Physical assessment reveals a dry sticky oral cavity. Which intervention should the nurse implement first for this client?

A. Encourage the client to drink 100 mL of water hourly.
B. Provide mouth care every 4 hours while awake.
C. Obtain an order for continuous intravenous fluid therapy.
D. Initiate monitoring of the client's intake and output.

Answer 1

The nurse should encourage the client to drink 100 mL of water hourly as the first intervention for this client with a dry sticky oral cavity and low intake and output. providing mouth care every 4 hours while awake (option B) and obtaining an order for continuous intravenous fluid therapy (option C) can be appropriate interventions.

Step-by-step explanation:

The nurse should implement intervention A: Encourage the client to drink 100 mL of water hourly as the first step for this client. The dry and sticky oral cavity indicates dehydration, which can be addressed by increasing fluid intake. Additionally, providing mouth care every 4 hours while awake (option B) and obtaining an order for continuous intravenous fluid therapy (option C) can be appropriate interventions, but they are not the most immediate priority in this situation.

implement intervention A: Encourage the client to drink 100 mL of water hourly as the first step for this client. The dry and sticky oral cavity indicates dehydration, which can be addressed by increasing fluid intake. Additionally, providing mouth care every 4 hours while awake (option B) and obtaining an order for continuous intravenous fluid therapy (option C) can be appropriate interventions, but they are not the most immediate priority in this situation.