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 c: Confusion is a finding that the nurse should anticipate in an older adult client who has cystitis, which is inflammation of the bladder caused by a bacterial infection. Confusion can be a sign of sepsis or delirium, which are common complications of urinary tract infections in older adults.

Choice a is not correct because hypothermia is not a finding that the nurse should anticipate in an older adult client who has cystitis. Hypothermia can occur in older adults due to impaired thermoregulation, but it is not related to cystitis.

Choice b is not correct because referred pain in the right shoulder is not a finding that the nurse should anticipate in an older adult client who has cystitis. Referred pain in the right shoulder can indicate gallbladder disease, but it is not related to cystitis.

Choice d is not correct because orange-colored urine is not a finding that the nurse should anticipate in an older adult client who has cystitis. Orange-colored urine can be caused by certain medications, foods, or dehydration, but it is not related to cystitis.

The correct answer is A:

Choice A reason:

Replace the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.

Choice B reason:

Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.

Choice C reason:

Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.

Choice D reason:

Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.