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?

Remove the coffee from the tray, advising the client that it is not included in the diet.

Determine which member of the nursing staff brought the cup of coffee to the client.

Remind the client that no milk or creamer can be added to the coffee.

Consult with the dietician to learn if the client is allowed to drink coffee.

Answer and Explanation

The Correct Answer is C

A. Removing the coffee might not be necessary if coffee is allowed on a clear liquid diet. The client may have been provided with the coffee based on dietary guidelines.
B. Determining which staff member brought the coffee does not address the immediate need to ensure dietary guidelines are followed.
C. On a clear liquid diet, coffee is typically allowed as long as it is consumed without milk or cream. Advising the client about this restriction ensures adherence to the diet and proper management of dietary restrictions.
D. Consulting with the dietician is important for confirming dietary guidelines but addressing the immediate situation with the client’s understanding of their diet is a more direct action.

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Correct Answer is C

Explanation

A. Asking an unlicensed assistive personnel (UAP) to stay with the client does not directly address the client's concern about being unable to make it to the bathroom.
B. Placing the bedpan within the client’s reach may help, but it is less comfortable and dignified than using a commode, which is a better option for an ambulatory client.
C. Obtaining a bedside commode for the client to use is the best intervention as it provides a practical solution that allows the client to relieve herself without the anxiety of having to walk a distance, thus preventing any accidents.
D. Notifying the healthcare provider of the client’s concerns is unnecessary as this situation can be effectively managed by nursing intervention.

A. Family attorney. B. Nurse manager. C. Hospice nurse. D. Chaplain.

Correct Answer is A

Explanation

A. A family attorney is the most appropriate professional to contact for more information about advance directives. Attorneys are knowledgeable about the legal aspects of advance directives, including living wills and durable power of attorney for healthcare, and can provide guidance on how to properly complete these documents.
B. A nurse manager may provide general information, but an attorney is more suited to address the legal aspects of advance directives.
C. A hospice nurse focuses on end-of-life care but may not have the expertise to provide comprehensive information about the legal requirements for advance directives.
D. A chaplain can offer spiritual support but is not the best resource for legal information regarding advance directives.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.