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

The appropriate response by the nurse in this situation would be to respect the young man's wish not to look at the wound during dressing changes. This response shows empathy and understanding toward the patient's feelings and emotions and allows him to have control over his own care. It is important for healthcare providers to respect their patient's autonomy and decisions regarding their own care.

A. Start cardiopulmonary resuscitation (CPR). B. Assist the client to a sitting position on the ﬂoor. C. Allow the visitor to cough. D. Assess for a weak ineﬀective cough. E. Perform the Heimlich maneuver.

Correct Answer is ["C","D"]

Explanation

If a visitor in the dining room at the hospital has a forceful cough, the nurse should first allow the visitor to continue coughing. Coughing is a natural reﬂex that helps clear the airway of foreign objects or mucus. The nurse should also assess the eﬀectiveness of the cough. If the cough is weak or ineﬀective, further intervention may be necessary.

Starting cardiopulmonary resuscitation (CPR) or performing the Heimlich maneuver would only be appropriate if the visitor is choking and unable to breathe. Assisting the client to a sitting position on the ﬂoor may not be necessary and could potentially cause harm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

Correct Answer is C

Explanation

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:

Correct Answer is ["C","D"]

Explanation

A nurse is providing care for a client who has recently been diagnosed with type 1 diabetes mellitus. To focus on aﬀective learning with this client, the nurse should use which of the following interventions?

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 conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?

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?

Which of the following principles does the nurse use in selecting interventions for the care plan?

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

A client with a terminal illness without an advance directive stops breathing and does not have a heartbeat. What should the nurse do?