Question

a nurse is collecting data for a client who has had diarrhea and decreased urination for several days. which of the following actions should the nurse take to determine if the client is dehydrated? push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.

Explanation:

Skin turgor is a common method to assess dehydration. Grasping a skin - fold on the chest under the clavicle and checking if it springs back is a way to evaluate skin turgor. Delayed return to normal position indicates dehydration. Pressing on a fingernail bed assesses capillary refill which is more related to circulation than dehydration directly. Pressing the skin above the ankle checks for pitting edema, not dehydration. Measuring skin - fold thickness with calipers is for body fat assessment, not dehydration.

Answer:

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.