The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery.
Which menu item(s) should the nurse request for this client? (Select all that apply).
Orange juice.
Apple juice.
Hot chocolate.
Chicken broth.
Black coffee.
Correct Answer : B,D
The correct answer is choice b. Apple juice and d. Chicken broth.
Choice A rationale:
Orange juice is a clear liquid and generally acceptable on a clear liquid diet. However, it is not the best choice for someone following Mormon beliefs due to its acidity, which might not be suitable post-surgery.
Choice B rationale:
Apple juice is a clear liquid and suitable for a clear liquid diet. It is also non-caffeinated and non-alcoholic, aligning with Mormon dietary restrictions.
Choice C rationale:
Hot chocolate contains caffeine and is not considered a clear liquid. It is not suitable for a clear liquid diet and does not align with Mormon dietary restrictions.
Choice D rationale:
Chicken broth is a clear liquid and suitable for a clear liquid diet. It is non-caffeinated and non-alcoholic, making it appropriate for someone following Mormon beliefs.
Choice E rationale:
Black coffee contains caffeine, which is prohibited in the Mormon diet. It is also not recommended on a clear liquid diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.
Choice B rationale:
Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
Choice C rationale:
Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.
Choice D rationale:
Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
Correct Answer is A
Explanation
Choice A rationale:
Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.
Choice B rationale:
Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.
Choice C rationale:
Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.
Choice D rationale:
Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.
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