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Practice Question

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?

Answer Choices:

Correct Answer:

Document that the problem has been resolved and the goal has been met.

Rationale:

➤ The absence of diarrhea and vomiting for five days confirms that the 48-hour elimination goal has been achieved, demonstrating effective fluid-volume management.

➤ Documenting goal attainment and problem resolution accurately reflects the nurse’s successful interventions and supports discontinuation of the diagnosis.

➤ Since the Risk for Deficient Fluid Volume did not materialize, noting resolution ensures the client’s fluid balance status is correctly updated.

➤ Removing a resolved risk diagnosis prevents redundant interventions and maintains an efficient, current care plan.

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This question is from ATI Fundamentals Final (II) which contains 69 questions.

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ATI Fundamentals Final (II)

69 Questions

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Question Details
  • Category: RN - Nursing Exam(s)
  • Subcategory: ATI Exams
  • Domain: ATI FUNDAMENTALS OF NURSING
  • Answer Choices: 4
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