A nurse is reviewing the laboratory test results for a male client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration?

A. Lubricating the suction catheter tip with sterile saline is generally not recommended. The catheter tip is usually not lubricated before suctioning. Instead, suctioning should be performed using a dry, sterile catheter to prevent introducing any substances into the airway that could cause irritation or infection.
B. Hyperoxygenating the patient with 100% oxygen before suctioning is a crucial step. This helps to prevent hypoxia during the suctioning procedure, as suctioning can temporarily reduce the oxygen levels in the blood. By providing 100% oxygen for 30 to 60 seconds, the nurse ensures that the patient has an adequate oxygen reserve and reduces the risk of oxygen desaturation during suctioning.
C. Performing chest physiotherapy is not a routine pre-suctioning action and is generally done as part of a separate management strategy for clearing secretions. Chest physiotherapy involves techniques such as percussion, vibration, and postural drainage to help mobilize secretions from the lungs.
D. Instilling normal saline into the airway before suctioning (known as “normal saline lavage”) is not recommended. This practice can actually cause harm, such as increasing the risk of infection, causing bronchospasm, and diluting secretions which may then become more difficult to suction.

A. This is a good method to gather feedback but does not directly assess the client's ability to perform the taught skills.
B. This is important to identify knowledge gaps but does not assess the client's ability to perform the skills.
C. This is the most direct way to assess the client's ability to perform the taught skill and ensures that the client has retained the information.
D. While important, vital signs do not directly assess the effectiveness of home care teaching.