A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following manifestations of dehydration?

Choice A reason: Slowing the rate to 50 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could cause the client to become more hypovolemic, which is a condition where there is a decreased volume of blood in the body. Hypovolemia can lead to shock, organ failure, and death.

Choice B reason: Slowing the rate to 20 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could also cause the client to become more hypovolemic, which is a serious and life-threatening condition. The nurse should not reduce the IV fluid rate without a physician's order.

Choice C reason: Increasing the rate to 250 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could cause the client to become more hypervolemic, which is a condition where there is an excess of fluid in the blood vessels. Hypervolemia can cause fluid overload, pulmonary edema, and heart failure.

Choice D reason: Continuing the rate at 125 mL/hr is an appropriate action by the nurse before calling the physician to clarify the order. This is a reasonable rate for a client who has a head injury and hypovolemia, as it can help restore the fluid balance and prevent cerebral edema. The nurse should not change the IV fluid rate without a physician's order.

Choice A reason: An antipyretic medication is not the best answer because it does not address the client's low urine output. An antipyretic medication is a drug that lowers the body temperature by reducing the production of heat or increasing the loss of heat. It may help the client feel more comfortable, but it does not improve the kidney function or prevent dehydration.

Choice B reason: A diuretic medication is not the best answer because it may worsen the client's low urine output. A diuretic medication is a drug that increases the excretion of water and electrolytes by the kidneys. It may lower the blood pressure and reduce the fluid overload, but it may also cause dehydration, electrolyte imbalance, and kidney damage.

Choice C reason: A blood culture is not the best answer because it does not address the client's low urine output. A blood culture is a laboratory test that detects the presence of bacteria or other microorganisms in the blood. It may help identify the cause of the fever and guide the antibiotic therapy, but it does not improve the kidney function or prevent dehydration.

Choice D reason: A fluid bolus is the best answer because it may improve the client's low urine output. A fluid bolus is a rapid infusion of a large volume of fluid, usually isotonic saline or lactated Ringer's solution. It may increase the blood volume and pressure, improve the tissue perfusion, and stimulate the urine production. It may also help lower the fever by diluting the pyrogens and increasing the heat loss.