A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Choice A rationale:

It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).

Early ambulation is generally encouraged to promote circulation and prevent blood clots.

Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.

Choice B rationale:

Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.

The patient's position should be based on their individual needs and comfort level.

In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.

Choice C rationale:

Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.

This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.

Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.

Choice D rationale:

Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.

This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.

If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.

Choice A rationale:

Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.

Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.

The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.

Choice B rationale:

Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.

These actions close off the airway and open the esophagus, creating a smoother path for the tube.

The nurse should instruct the patient to perform these actions during insertion to promote successful placement.

Choice C rationale:

While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.

Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.

The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.

Choice D rationale:

Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).

This landmark-based method provides a more reliable estimation of the distance to the stomach.