A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
How many popsicles are available.
If the popsicles are completely frozen.
The color and flavor of gelatin used.
Whether they contain pulp or fruit.
The Correct Answer is D
A. How many popsicles are available.
This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.
B. If the popsicles are completely frozen.
While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.
C. The color and flavor of gelatin used.
While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.
D. Whether they contain pulp or fruit.
For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct answer: C
A. Irrigate the nasogastric tube with water:
This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.
B. Perform oropharyngeal suctioning:
In this scenario, the client is experiencing an acute, life-threatening event (choking/aspiration risk). You must apply the ABC (Airway, Breathing, Circulation) priority framework.
C. Elevate the head of bed 45 degrees:
Elevating the head of the bed to 45 degrees is a great preventative measure to avoid aspiration, but once the client is already vomiting and choking, you need to physically clear the airway.
D. Review the advance directive document:
Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.
Correct Answer is B
Explanation
A. Capillary refill of 2 seconds in the lower right foot:
Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.
B. Basilar lung sounds that are diminished in the left lung:
Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.
C. Contraction of the left pupil when light shines in the right eye:
Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.
D. Active bowel sounds in the lower right quadrant:
Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.
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