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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight oﬀ the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.

A. Encourage his daughter to prepare food at home and bring it to the client. B. Provide bland meals. C. Provide distractions while the client is fed so that he will eat more. D. Serve large meals and encourage the client to eat as much as possible.

Correct Answer is A

Explanation

The nurse should implement the measure of encouraging the client's daughter to prepare food at home and bring it to the client. This can help improve the client's nutritional intake by providing familiar and appetizing meals that may be more appealing to the client than hospital food. It is important for the nurse to work with the client and their family to identify strategies that can help improve the client's nutritional intake during their hospitalization.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

Correct Answer is D

Explanation

The nurse has been caring for a client for several days and has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake?

Correct Answer is A

Explanation

The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. Members of which cultural group might request an alternative meal choice?

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

The nurse has performed an assessment of a client scheduled for discharge to be cared for by the family. Which situation would the nurse question regarding discharge of this client to be cared for by the family?

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me an antibiotic." What would be the most appropriate response by the nurse?

During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse hooks the client to the medication infusion. Which role is the nurse performing at this time?

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. How should the nurse respond?

While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor? Select all that apply: