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. While it is important to address unprofessional behavior, directly warning the colleague may not be sufficient to address the breach of security protocols effectively.
B. Discussing the action at a staff meeting may not address the immediate issue and could lead to general discussions rather than specific corrective actions.
C. Communicating the observation to the charge nurse is appropriate because it ensures that the issue is reported to a person who can take immediate action to address the breach of EHR security and prevent further unauthorized access.
D. Filing a detailed incident report may be necessary, but first, informing the charge nurse is crucial for immediate action and to address the issue promptly. The charge nurse can then guide the next steps, including filing a report if necessary.

A. Suggest using a stool softener. B. Recommend a daily laxative. C. Obtain a stool specimen. D. Discuss oral analgesic options.

Correct Answer is A

Explanation

A. Suggesting a stool softener is appropriate as it helps to ease bowel movements and reduce straining, which can alleviate pain associated with hemorrhoids and help establish a regular bowel pattern.
B. Recommending a daily laxative may not be appropriate for long-term use and could potentially exacerbate the issue if overused. It is generally better to start with less invasive measures like stool softeners.
C. Obtaining a stool specimen may be necessary for diagnostic purposes but does not directly address the immediate concern of painful defecation due to hemorrhoids.
D. Discussing oral analgesic options might help with pain management, but it does not address the underlying issue of constipation and the need for a regular bowel pattern. Stool softeners are more directly related to resolving the constipation problem.

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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

The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?

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The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?

Correct Answer is A

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