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
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Correct Answer is A
Explanation
In this situation, the nurse is performing the role of an educator. The nurse is explaining the procedures for preventing infection in a central venous access device to the spouse and demonstrating how to hook the client to the medication infusion.
Correct Answer is C
Explanation
A client who has accepted the fact that they need bypass surgery for a blocked artery and has been admitted to the hospital is experiencing Stage 2 of illness. Stage 2 is known as the prodromal period, during which the symptoms of illness begin to appear ². The other options (Stage 1, Stage 3, and Stage 4) are not correct.

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