A nurse is caring for a client who has a gastrostomy tube and is receiving enteral nutrition. The nurse should identify that which of the following complications represents the greatest risk to the client?

Choice A reason: Elastic skin turgor is a sign of adequate hydration and fluid balance. Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled. When the skin is dehydrated, it loses its elasticity and becomes tented or wrinkled. The nurse should assess the skin turgor on the chest, abdomen, or forehead, and not on the hands or feet, which can be affected by aging or edema.

Choice B reason: Dry mucous membranes are a sign of fluid volume deficit, not fluid volume excess. Mucous membranes are the moist linings of the mouth, nose, eyes, and other body openings. When the body is dehydrated, the mucous membranes become dry, cracked, or sticky. The nurse should assess the mucous membranes for color, moisture, and capillary refill.

Choice C reason: Oliguria is a sign of fluid volume deficit, not fluid volume excess. Oliguria is the production of abnormally small amounts of urine, usually less than 400 mL per day or 30 mL per hour. Oliguria can indicate reduced kidney function, impaired blood flow to the kidneys, or inadequate fluid intake. The nurse should monitor the urine output, color, specific gravity, and presence of blood or protein.

Choice D reason: Tachycardia is a sign of fluid volume deficit, not fluid volume excess. Tachycardia is a rapid heart rate, usually more than 100 beats per minute. Tachycardia can occur when the body is dehydrated, as the heart tries to pump more blood to maintain the blood pressure and perfusion. The nurse should measure the pulse rate, rhythm, quality, and amplitude.

Choice C reason: This statement shows that the client has understood the importance of vitamin D and calcium for bone health. Fortified milk, fatty fish, and cheese are good sources of both nutrients, which help to maintain bone density and prevent osteoporosis.

Choice A reason: This statement is incorrect, as vitamin A supplementation can have adverse effects on bone health. Excessive intake of vitamin A can increase the risk of fractures and reduce bone mineral density.

Choice B reason: This statement is partially correct, as calcium supplementation can help to meet the daily requirement of calcium for bone health. However, calcium alone is not enough, as vitamin D is also needed to facilitate the absorption of calcium and prevent its loss from the bones.

Choice D reason: This statement is irrelevant, as none of the foods mentioned are particularly beneficial for bone health. Orange juice, lean meats, and egg whites are good sources of vitamin C, protein, and biotin, respectively, but they do not provide significant amounts of vitamin D or calcium.