A hydration assessment consists of checking a variety of ...

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A hydration assessment consists of checking a variety of parameters, including
 
  a. skin turgor.
  b. serum potassium level.
  c. capillary refill.
  d. serum protein level.

Question 2

Upon auscultation, the nurse hears borborygmi. This is a change in the patient's condition. The nurse suspects the patient maybe experiencing
 
  a. a complete ileus.
  b. early intestinal obstruction.
  c. abnormality of blood flow.
  d. peritonitis.

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Answer to Question 1

A
A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.

Answer to Question 2

B
Hyperactive bowel sounds (borborygmi) that are loud and prolonged are caused by hunger, gastroenteritis, or early intestinal obstruction. Decreased (hypoactive) bowel sounds are symptoms of possible peritonitis or ileus. Bruits are caused by abnormality of blood flow.