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 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.

A. Keep the medication and see if the client will want to take it later. B. Credit the medication back and put it in the client's medication box. C. Explain that since the medication is a controlled substance it must be taken. D. Have another nurse watch the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

A. The medication should not be kept or stored once it has been removed from its original packaging, especially if it’s not administered. Proper disposal or return to the pharmacy is required.
B. The medication should not be put back in the client’s medication box due to safety and contamination concerns.
C. While controlled substances need careful management, the client’s refusal must be respected, and the medication must be disposed of properly if not administered.
D. Having another nurse witness the disposal of the medication ensures that it is done according to protocols and provides accountability. This practice helps maintain the integrity and safety of medication handling.

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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

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

Explanation

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Correct Answer is D

Explanation

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