A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit?

A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.

B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.

C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.

D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.

A.

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.