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.

The correct answer is Choice A.

Choice A rationale: Encouraging increased fluid intake helps maintain blood volume and reduces viscosity, promoting circulation and lowering the risk of venous stasis and clot formation postoperatively.

Choice B rationale: Keeping the affected knee flexed impairs venous return and increases stasis, elevating the risk of thrombosis. Proper positioning with extension promotes circulation and reduces clot risk.

Choice C rationale: Prolonged bed rest contributes to immobility-induced venous stasis, a major risk factor for DVT. Early ambulation and leg exercises are essential to prevent thromboembolic events.

Choice D rationale: Massaging the calf of a postoperative patient is contraindicated due to the risk of dislodging a thrombus, potentially leading to a life-threatening pulmonary embolism.