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 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.

A. Bradycardia. B. Bigeminal. C. Dysrhythmia. D. Tachycardia.

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.

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Naxlex Comprehensive Predictor Exams

A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn?

Correct Answer is A

Explanation

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 is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Select all that apply.

The attributes of a professional nurse are: