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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Serum potassium and sodium levels are not relevant to the assessment of the wound infection. They are electrolytes that regulate fluid balance, nerve conduction, and muscle contraction. They may be affected by dehydration, renal failure, or diuretics.

Choice B reason: Neutrophil count is the most relevant laboratory value to note before reporting the wound infection. Neutrophils are white blood cells that fight bacterial infections and inflammation. A high neutrophil count indicates an acute infection or inflammation, while a low neutrophil count indicates a compromised immune system or a chronic infection.

Choice C reason: Blood pH level is not relevant to the assessment of the wound infection. It is a measure of the acidity or alkalinity of the blood. It may be affected by respiratory or metabolic disorders, such as acidosis or alkalosis.

Choice D reason: Hematocrit is not relevant to the assessment of the wound infection. It is the percentage of red blood cells in the blood. It may be affected by anemia, dehydration, or polycythemia.

A. Review the advanced directive document. B. Elevate the head of the bed 45 degrees. C. Perform oropharyngeal suctioning. D. Irrigate the nasogastric tube with water.

Correct Answer is C

Explanation

Choice A reason: Reviewing the advanced directive document is not the priority action. The nurse should first intervene to clear the airway and prevent aspiration of vomitus.

Choice B reason: Elevating the head of the bed 45 degrees is a good practice, but it is not sufficient to relieve the choking. The nurse should also perform suctioning to remove the vomitus from the mouth and throat.

Choice C reason: Performing oropharyngeal suctioning is the best action as it helps to clear the airway and prevent aspiration of vomitus. The nurse should use a Yankauer suction catheter and apply intermittent suction while moving the catheter around the mouth and throat.

Choice D reason: Irrigating the nasogastric tube with water is not appropriate as it may worsen the vomiting and choking. The nurse should stop the enteral feeding and clamp the tube until the client's condition is stabilized.

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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?

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Naxlex Comprehensive Predictor Exams

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

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 C

Explanation

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