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 D

Explanation

D. Hinge joints are primarily involved in flexion and extension movements. In the case of the arm, the elbow joint is a hinge joint, and bending the arm by flexing the ulna (forearm bone) toward the humerus (upper arm bone) is an example of a movement that exercises this type of joint.

A. This action primarily involves the cervical (neck) spine and the atlantoaxial joint, allowing rotation of the head from side to side. However, these are not hinge joints

B. This action involves movements of the shoulder joint, which is a ball-and-socket joint allowing for a wide range of motion.

C. Tilting the pelvis forwards and backwards primarily involves movements of the hip joint, which is also a ball-and-socket joint.

A. Provide comfort measures such as topical warm application and tactile massage. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Determine client's subjective-measure of pain using a numerical pain scale.

Correct Answer is ["A","B","E"]

Explanation

A. Provide comfort measures such as topical warm application and tactile massage. Comfort measures can help alleviate chronic pain symptoms and provide relief to the client.

B. Implement a 24-hour schedule of routine administration of prescribed analgesic. Consistent administration of prescribed analgesics helps maintain pain control and manage chronic pain effectively.

E. Determine the client's subjective measure of pain using a numerical pain scale. Assessing the client's pain using a numerical pain scale allows for quantification of pain intensity, which helps guide pain management interventions and evaluate effectiveness.

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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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