A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

A. Skin tenting occurs when the skin loses its elasticity due to dehydration. When gently pinched, the skin may remain elevated and return to its normal position slowly. This finding is a classic sign of dehydration and indicates that the client has lost significant fluid volume.
B. Elevated blood pressure (BP) can sometimes be associated with dehydration, especially in acute cases or when there are underlying conditions like hypovolemia. However, it is not typically a primary indicator of dehydration. Hypotension (low blood pressure) is more commonly associated with severe dehydration.
C. Red mucous membranes may indicate various conditions, including dehydration. Dehydration can lead to dryness and mucosal irritation, resulting in redness. However, red mucous membranes alone are not specific enough to reliably indicate dehydration without considering other signs and symptoms.

D. Jugular vein distention (JVD) is associated with fluid overload rather than dehydration. It occurs when there is increased pressure in the venous system, often due to heart failure or fluid retention. JVD is not typically seen in dehydrated individuals.

A. There is no indication of an emergency based on black stools alone without other concerning symptoms such as severe abdominal pain, cramping, or signs of gastrointestinal bleeding.
B. While gathering more information about the client's diet may be helpful in some cases, it does not address the specific concern about the black stools related to iron supplementation.
C. Unless there are other concerning symptoms, such as gastrointestinal bleeding or significant discomfort, this situation does not typically warrant an immediate visit to the office. It can be managed with reassurance and education over the phone.
D. Iron supplements commonly cause stools to turn black due to the way iron is metabolized in the digestive system. This change in stool color is known as "iron-induced blackening." It occurs because iron supplements contain iron salts that undergo chemical reactions in the gastrointestinal tract, resulting in the production of iron sulfide compounds that impart a black color to the stool.