An older adult who is on bed rest has tachycardia and dry mucous membranes after surgery.Which of the following is the nurse's priority for preventive care because of the patient's fluid volume status?

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This older adult is at high risk for a thromboembolic event as a result of bed rest and dehydration.Because it is a potentially life-threatening situation,the nurse's priority is to prevent a thromboembolic event,including deep venous thrombosis and pulmonary embolism.The patient is likely to have low circulating blood volume as evidenced by tachycardia,which is a compensatory mechanism when the tissues receive inadequate oxygenation.In addition,compensatory mechanisms that help restore fluid balance are limited in the older adult.This limitation results in poorer tissue perfusion and an increased risk for thrombus formation for a patient who is on bed rest; a lack of skeletal muscle action promotes pooling of blood in the extremities.
Dehydration can lead to constipation and,in extreme cases,a bowel obstruction; however,this potential gastrointestinal issue is not the nurse's priority because circulation issues take precedence.Dehydration increases the risk of delirium,especially in a patient who is hospitalized,but dehydration has a lower priority than the circulation issue.Dehydration increases the risk of delayed wound healing; optimal wound healing occurs in a moist environment.However,delayed wound healing is a secondary concern until the nurse manages the circulation issue.

An Older Adult Who Is on Bed Rest Has Tachycardia