The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

Choice A reason: Reduced skin turgor, a sign of fluid volume deficit, occurs due to decreased interstitial fluid, reducing skin elasticity. Dehydration from fluid loss impairs cellular hydration, slowing skin recoil. This is a key assessment finding, as it reflects low extracellular fluid volume, affecting tissue perfusion and requiring fluid replacement to restore homeostasis.

Choice B reason: Decreased blood pressure results from fluid volume deficit, reducing intravascular volume and cardiac output. Low fluid decreases venous return, triggering baroreceptors to signal sympathetic activation, though insufficient to maintain pressure. This is a critical sign, as it indicates compromised perfusion to organs, necessitating fluid resuscitation to restore hemodynamic stability.

Choice C reason: Increased urine output is incorrect, as fluid volume deficit reduces urine output due to decreased renal perfusion. The kidneys conserve fluid via antidiuretic hormone and renin-angiotensin-aldosterone system activation, concentrating urine. This sign does not correlate with dehydration, which typically presents with oliguria, making it an incorrect assessment finding.

Choice D reason: Increased heart rate (tachycardia) compensates for fluid volume deficit, as reduced blood volume lowers cardiac output. Sympathetic activation increases heart rate to maintain tissue perfusion despite low fluid. This is a key sign, reflecting the body’s attempt to compensate for hypovolemia, requiring fluid replacement to normalize cardiovascular function.

Choice E reason: Dry mouth and skin are classic signs of fluid volume deficit, as dehydration reduces salivary gland secretion and skin moisture. Low extracellular fluid impairs mucous membrane hydration and sweat production. These signs indicate systemic fluid loss, affecting cellular function and requiring documentation to guide fluid therapy for restoring hydration and tissue perfusion.

Choice A reason: Assessing involves collecting data, like vital signs or skin condition, to identify patient needs. Turning a client every 2 hours follows an established plan to prevent pressure ulcers, not data collection. Assessment informs care plans, but turning is an action, not an evaluation of physiological status, making this incorrect.

Choice B reason: Planning involves setting goals and interventions, like scheduling turns to prevent pressure ulcers. Turning a client every 2 hours is executing that plan, not creating it. Planning addresses skin integrity and tissue perfusion needs, but the act of turning is the implementation phase, making this an incorrect choice.

Choice C reason: Implementing is the execution of the care plan, such as turning a client every 2 hours to prevent pressure ulcers. This action maintains skin integrity by reducing pressure on tissues, promoting blood flow and oxygenation. It follows the plan’s directives, aligning with the nursing process’s action phase, making this the correct choice.

Choice D reason: Evaluating assesses the effectiveness of interventions, like checking skin integrity after turning. Turning a client every 2 hours is the intervention itself, not its evaluation. Evaluation measures outcomes, like reduced pressure ulcer risk, but the act of turning is implementation, addressing tissue perfusion, making this incorrect.