The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Remind the client no milk or creamer can be added to the coffee.

Determine which member of the nursing staff brought the cup of coffee to the client.

Remove the coffee from the tray, advising the client that it is not included in the diet.

Consult with the dietitian to learn if the client is allowed to drink coffee.

Answer and Explanation

The Correct Answer is C

C. A clear liquid diet typically includes transparent or translucent liquids that are easy to digest and leave minimal residue in the gastrointestinal tract. Coffee, especially if it contains milk or creamer, is not considered a clear liquid and is not usually permitted on a clear liquid diet.

A. Reminding the client no milk or creamer can be added to the coffee may be appropriate for clients on other dietary restrictions but does not address the issue of coffee not being part of a clear liquid diet.

B. Determining which member of the nursing staff brought the cup of coffee to the client is not necessary unless there is a need to investigate a specific incident or identify potential lapses in care.

D. Consulting with the dietitian to learn if the client is allowed to drink coffee may be appropriate for clarifying dietary restrictions or allowances, but in the context of a clear liquid diet, coffee is typically not permitted regardless of the dietitian's input.

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Correct Answer is B

Explanation

A. Emptying the sample into the 24-hour container would mix the previously voided urine with the new collection, leading to inaccurate results.

B. The nurse should discard the urine that was collected earlier and start the collection process anew with the next void. This ensures that the entire 24-hour urine output is collected accurately.

C. The collection can be started immediately with the next void, even if it's a few hours after the original start time.

D. Observing the sample for sediment does not address the need for a complete 24-hour collection.

A. Advise the client that lifestyle changes often take several weeks to be effective. B. Determine the amount of weight the client has lost since increasing activity. C. Encourage the client to exercise every day to eliminate bedtime wakefulness. D. Ask the client to describe the exercise schedule that he has been following.

Correct Answer is D

Explanation

D. The most appropriate action for the nurse to take is to gather more information about the client's exercise schedule. This will help the nurse assess whether the client's exercise regimen may be contributing to or exacerbating the insomnia. Understanding the timing, intensity, and duration of the client's aerobic workouts can provide insights into potential factors affecting sleep patterns.

A. Advising the client that lifestyle changes often take several weeks to be effective is a valid point. However, it does not directly address the potential impact of exercise timing on sleep.

B. Determining the amount of weight the client has lost since increasing activity may provide useful information about the client's progress with weight loss but does not directly address the issue of difficulty falling asleep.

C. Encouraging the client to exercise every day to eliminate bedtime wakefulness is not necessarily appropriate, as excessive or late-night exercise may exacerbate rather than alleviate bedtime wakefulness in some individuals.

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The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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