Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)

Choice A reason: Sunken eyes are a sign of dehydration because the fluid loss causes the eyes to lose their shape and appear hollow. This is especially noticeable in older adults who have less fat and muscle around the eyes.

Choice B reason: Lower extremity weakness is a sign of dehydration because the fluid loss affects the blood volume and circulation, leading to reduced oxygen and nutrient delivery to the muscles. This can cause muscle fatigue, cramps, and weakness.

Choice C reason: High fever is not a sign of dehydration, but rather a possible cause of dehydration. Fever increases the body temperature and metabolic rate, which leads to increased sweating and fluid loss. However, fever itself does not indicate dehydration, unless it is accompanied by other signs and symptoms.

Choice D reason: Cough is not a sign of dehydration, but rather a possible cause of dehydration. Coughing can cause fluid loss through the respiratory tract, especially if it is productive or associated with vomiting. However, cough itself does not indicate dehydration, unless it is accompanied by other signs and symptoms.

Choice A reason: This is the correct answer because the nurse should assess the patient's pain level and location, even if he denies pain. The patient's vital signs indicate that he may be experiencing pain, as increased heart rate, respiration rate, and blood pressure are common physiological responses to pain. Pain can also be masked by other factors, such as fear, anxiety, or stoicism. Therefore, the nurse should ask the patient about his comfort and use a valid pain assessment tool, such as the numeric rating scale or the faces pain scale, to measure his pain intensity.

Choice B reason: This is incorrect because the nurse should not administer an opioid medication by IV route without assessing the patient's pain level and location first. Opioid medications are potent analgesics that can relieve severe pain, but they can also cause serious side effects, such as respiratory depression, sedation, nausea, vomiting, constipation, or dependence. The nurse should follow the principles of pain management, such as using the lowest effective dose, titrating the dose according to the patient's response, and monitoring the patient for adverse effects. The nurse should also consider using non-pharmacological interventions, such as ice packs, elevation, or distraction, to complement the pharmacological therapy.

Choice C reason: This is incorrect because the nurse should not check the surgical dressing for bleeding without assessing the patient's pain level and location first. Checking the surgical dressing for bleeding is an important intervention to monitor the patient's wound healing and prevent infection, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can impair wound healing and increase the risk of complications. The nurse should also obtain the patient's consent and explain the procedure before checking the surgical dressing, as this can cause discomfort and anxiety.

Choice D reason: This is incorrect because the nurse should not report the vital signs to the health care provider without assessing the patient's pain level and location first. Reporting the vital signs to the health care provider is an important intervention to communicate the patient's condition and obtain further orders, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can affect the vital signs and the patient's well-being. The nurse should also document the patient's pain assessment and intervention in the medical record, as this can facilitate the continuity of care and evaluation of outcomes.