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 B
Explanation
When educating a preoperative client on how to effectively deep breathe, the nurse should instruct the client to make each breath deep enough to move the bottom ribs. This helps to ensure that the client is taking deep breaths and fully expanding their lungs. The other options (Breathe in through the mouth and out through the nose, Practice deep breathing at least once each week, and Breathe through the mouth when you inhale and exhale) are not accurate instructions for effective deep breathing.
Correct Answer is A
Explanation
The nurse should instruct the client to include more whole grains in their diet and drink more water daily to improve their inconsistent fecal elimination pattern. Whole grains are high in fiber which can help regulate bowel movements and drinking more water can help keep stools soft and easy to pass ¹. Using enemas as desired is not a recommended solution for long-term management of inconsistent fecal elimination patterns. It is important for the client to consult with their healthcare provider for personalized advice and treatment options.
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