The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

A. Temperature is important but does not directly address the immediate concern of cyanosis, which suggests possible issues with oxygenation.
B. Blood pressure is also important, but in the context of cyanosis, assessing the respiratory status is more directly related to identifying the cause of decreased oxygenation.
C. Heart rate is crucial for assessing circulatory status, but cyanosis often indicates a problem with oxygenation, making it less immediately relevant compared to respiratory assessment.
D. Respiratory rate should be assessed first as cyanosis can indicate impaired oxygenation, which is often due to respiratory issues. Evaluating the respiratory rate helps determine if there is a problem with breathing or gas exchange that needs immediate attention.

• Gather materials to change soiled items only: Not indicated. The nurse should gather all necessary materials for the entire wound care procedure, not just for changing soiled items, to ensure the dressing change is performed efficiently and effectively.
• Thoroughly clean wound using normal saline prior to redressing: Indicated. Proper wound cleaning with normal saline helps remove debris and reduce bacterial load, preparing the wound for the application of new dressings.
• Place sterile gauze directly on wound bed: Not indicated. The wound care order specifies the use of anasept gel covered with foam dressing. Sterile gauze is not the appropriate dressing in this scenario.
• Apply sterile gloves prior to changing: Indicated. Sterile gloves are necessary to maintain sterility and prevent infection during the dressing change procedure.
• Apply sterile foam dressing over wound bed: Indicated. The orders specify the use of a foam dressing after applying anasept gel, which provides the necessary coverage and protection for the wound.
• Maintain clean medical asepsis: Not indicated. While maintaining a clean environment is important, sterile technique (rather than clean medical asepsis) is required for this dressing change to prevent infection and promote healing in the wound bed.