A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?

Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.

Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.

Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.

Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.

Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.

Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.

Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.

Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.