The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
Consult with the dietitian to learn if the client is allowed to drink coffee.
Remind the client that 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.
The Correct Answer is B
Choice A reason: Consulting with the dietitian to learn if the client is allowed to drink coffee is not the best action to take. The nurse should already know the components of a clear liquid diet, which do not include coffee. Coffee is a stimulant that can irritate the gastrointestinal tract and interfere with the healing process.
Choice B reason: This is the correct action. A clear liquid diet allows for transparent liquids that leave no residue, such as black coffee. Adding milk or creamer would render the coffee opaque, making it unsuitable for a clear liquid diet. Therefore, it's appropriate to remind the client to consume the coffee without any additives.
Choice C reason: Determining which member of the nursing staff brought the cup of coffee to the client is not a priority action to take. The nurse should focus on the client's safety and well-being, not on assigning blame or finding fault. The nurse can address the issue with the staff later, after ensuring the client's needs are met.
Choice D reason: Removing the coffee is unnecessary, as black coffee is permitted on a clear liquid diet. Instead, the nurse should ensure the client understands not to add any prohibited substances like milk or creamer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect action as it indicates poor posture and balance. The client should walk with the elbows slightly flexed and the shoulders relaxed.
Choice B reason: This is the correct action as it ensures proper fit and comfort of the crutch. The client should fit the crutch 2 finger widths from the axilla to prevent nerve damage and pressure ulcers.
Choice C reason: This is an incorrect action as it may cause pain and injury to the wrists and hands. The client should adjust the height of the hand grips to allow a 30-degree bend at the elbow.
Choice D reason: This is an incorrect action as it may cause instability and falls. The client should hold the crutch 4 to 6 inches (10 to 15 cm) in front and to the side of the foot.
Correct Answer is B
Explanation
Choice A reason: Printing electronic medical record (EMR) from backup server is not the best action to take first. It may not be possible or feasible to access the backup server if the system is down. It may also delay the communication and delivery of the prescriptions to the lab.
Choice B reason: Notifying information services department of the situation is the best action to take first. It alerts the experts who can troubleshoot and fix the problem as soon as possible. It also allows the nurse to obtain guidance on how to proceed with the documentation and prescriptions.
Choice C reason: Identifying information as late entry in the record is a relevant action to take, but not the first one. It ensures the accuracy and completeness of the EMR, but it does not address the immediate issue of the system failure. The nurse may not be able to enter the information until the system is restored.
Choice D reason: Waiting for notification that the system has been rebooted is not a proactive action to take first. It may waste valuable time and compromise the client's care. The nurse should not assume that the system will be rebooted automatically or quickly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today