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 A

Explanation

A. Elevate the head of bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting.

B. Irrigating the nasogastric tube with water is not the most appropriate action in this scenario. While it may help clear any obstructions in the tube itself, it does not directly address the immediate concern of clearing the airway of vomitus to prevent aspiration.

C. While suctioning is an effective intervention for clearing the airway, if the client is in a choking situation, establishing a safe position (like elevating the head of the bed) is a priority before any suctioning is performed.

D. Reviewing the advance directive document is important for understanding the client's wishes regarding medical interventions, including resuscitation and life-sustaining treatments.

A. Encourage the use of incontinence briefs. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Insert a rectal tube at specified intervals.

Correct Answer is B

Explanation

B. This timing is based on the gastrocolic reflex, which typically triggers bowel movements shortly after eating. By assisting the client to the commode after meals, the nurse can take advantage of this reflex and increase the likelihood of successful bowel evacuation, reducing the risk of fecal incontinence episodes.

A. Incontinence briefs can provide containment for fecal incontinence and help manage soiling of clothing and bedding. However, they do not address the underlying issue of fecal incontinence or contribute to bowel training.

C. Administering a glycerin suppository after meals may stimulate bowel movements, but it does not address the underlying causes of fecal incontinence or promote bowel training.

D. Inserting a rectal tube at specified intervals may be indicated for fecal management in certain clinical situations, but it is not typically used as a primary intervention for bowel training in clients with chronic fecal incontinence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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