A nurse is collecting data about the fluid status of four patients.
Which patient should the nurse identify as being at risk for fluid volume deficit?

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Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement.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.

Choice A rationale:

Painful urination (dysuria) can be a sign of several conditions that could potentially affect the client's IVP or indicate a need for further assessment. These conditions include:

Urinary tract infection (UTI): UTIs are common in clients with recurrent kidney stones, and they can cause inflammation and pain in the urinary tract. If a client has a UTI, it's important to treat it before the IVP to reduce the risk of spreading the infection to the kidneys.

Kidney stone passage: The client's history of kidney stones makes it possible that the pain could be due to the passage of a stone. This would be important information for the healthcare team to know, as it could affect the interpretation of the IVP results.

Other urological conditions: There are other urological conditions, such as bladder or urethral strictures, that can also cause painful urination. These conditions might also need to be considered and assessed for.

It's important for the nurse to collect more data about the client's painful urination to determine the underlying cause and whether it could impact the IVP. This might include asking questions about:

The severity and duration of the pain

Any other associated symptoms, such as fever, urgency, or frequency The client's history of UTIs or kidney stones

Any recent changes in urinary habits

Based on this additional information, the nurse can then collaborate with the healthcare team to determine the best course of action, which might include:

Further assessment, such as a urinalysis or urine culture Treatment for a UTI, if present

Pain management

Rescheduling the IVP, if necessary