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 C

Explanation

Values clarification is the process of assisting another to clarify their own values in order to facilitate decision-making ¹. In this case, the client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counseling practice and work full-time. This demonstrates that the client has prioritized her values and made a decision based on them.

A. Extinguish the fire if possible. B. Rescue the client from immediate danger. C. Activate the fire alarm system. D. Confine the fire by closing doors and windows.

Correct Answer is B

Explanation

The first action the nurse should take in this situation is to rescue the client from immediate danger. This means ensuring that the client is safely removed from the room and away from the fire. The safety of the client is the top priority in this situation. Once the client is safe, the nurse can then take further actions such as activating the fire alarm system and attempting to extinguish the fire if possible.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counselling practice and work full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

Correct Answer is C

Explanation

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is taking care of a client who just lost her husband to a terminal illness. The client is refusing to believe that the loss is happening. Which of Kubler-Ross's stages of grieving is the client experiencing?

A nurse is evaluating a nursing student's understanding of positioning clients. Which of the following statements indicates a need for further teaching?

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping eﬀectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

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 nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

When a labor and delivery nurse tells a co-worker that a client of Asian descent probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as what?