A nursing diagnosis of "Risk for Deficient Fluid Volume" related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days. What should the nurse do?
Document that the potential problem is being prevented from recurring.
Document that the problem has been resolved and the goal has been met.
Assume that whatever the cause was, the symptoms may return, but the goal was met.
Keep the problem on the care plan in case the symptoms return.
The Correct Answer is B
The nursing diagnosis was "Risk for Deficient Fluid Volume" related to excessive fluid loss, secondary to diarrhea and vomiting. The goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days, indicating that the problem has been resolved. Therefore, the nurse should document that the problem has been resolved and the goal has been met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should immediately report a respiratory rate of 8 to the physician. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A respiratory rate of 8 is considered abnormally low and can indicate respiratory depression, which can be a side effect of pain medication delivered through an epidural catheter. It is important for the nurse to report this finding immediately so that appropriate interventions can be taken to ensure the safety of the client.
Correct Answer is A
Explanation
The best way to increase the client's motivation to learn is by encouraging their participation each time the procedure is performed. This can help the client feel more involved in their own care and increase their confidence in performing the procedure. The other options (Offering to do the procedure for the client each time it is scheduled, Teaching the client's support system how to perform the procedure, and Demonstrating the finger stick procedure to the nurse) may not be as effective in increasing the client's motivation to learn.
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