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. To assess fever patterns accurately in a client with a fever of unknown origin, the nurse should measure the temperature at regular intervals. This helps in identifying trends and patterns in the fever, such as spikes at specific times of the day or consistent elevations. Regular temperature measurements provide valuable information for the healthcare team to diagnose and manage the underlying cause of the fever effectively.

A. Assessing for flushed, warm skin can be indicative of fever, due to vasodilation and skin flushing. While this assessment can provide subjective clues about the presence of fever, it does not provide comprehensive information about fever patterns over time.

B. Different sites may reflect variations in temperature due to local factors or differences in blood flow. However, while varying sites can contribute to a comprehensive assessment of body temperature, it does not specifically address the need to assess fever patterns over time.

C. While circadian rhythms can influence temperature variations, particularly in relation to sleep- wake cycles, documenting circadian rhythms alone does not provide specific information about fever patterns.

A. 1.015. B. 1.025. C. 1.005. D. 1.035.

Correct Answer is D

Explanation

D. Given the client's history of vomiting, diarrhea, and difficulty tolerating oral fluids, there's a likelihood of dehydration. Dehydration typically results in an increase in urine specific gravity due to the kidneys conserving water.

A. (1.015) and B (1.025) are within the reference range and would be more typical values for adequately hydrated individuals.

C. (1.005) is at the lower end of the reference range and would not be expected in a dehydrated individual.

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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 client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse is assessing a client who reports a 3-day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

Correct Answer is D

Explanation

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