Which nursing measure should a nurse include in the care plan to encourage a client to increase fluid intake?
Placing a fresh water pitcher on the bedside table.
Offering frequent servings of preferred fluids.
Explaining the problems of inadequate intake.
Stressing the importance of drinking fluids.
The Correct Answer is B
This is because offering fluids that the client likes and in small amounts can help increase the client’s fluid intake and prevent dehydration. According to, some other nursing measures that can help improve the client’s nutritional intake are:
- Encouraging favorite foods from home, when possible.
- Providing frequent oral hygiene.
- Providing a pleasant environment during mealtime.
- Providing assistance with eating, if needed.
Choice A is wrong because placing a freshwater pitcher on the bedside table may not be enough to motivate the client to drink more fluids, especially if the client does not like plain water or has difficulty reaching for the pitcher.
Choice C is wrong because explaining the problems of inadequate intake may not be effective in changing the client’s behavior, and may even cause anxiety or resentment.
Choice D is wrong because stressing the importance of drinking fluids may also be ineffective or counterproductive, as it may sound like nagging or lecturing to the client.
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Correct Answer is D
Explanation
“I can use clean instead of sterile technique to suction my tracheostomy.” This statement demonstrates that the client understands how to care for their tracheostomy at home. According to the American Thoracic Society, clean technique can be used for suctioning at home, as long as the equipment is cleaned and stored properly.
Choice A is wrong because the client should be able to take care of their own tracheostomy as much as possible, with the help of a caregiver if needed. This promotes independence and self-care.
Choice B is wrong because the client should not be the only one who knows how to suction their tracheostomy at home. They should have at least one backup person who can assist them in case of an emergency or if they are unable to do it themselves.
Choice C is wrong because the client should not use saline for longer than 24 hours, even if they boil it.
Saline can become contaminated with bacteria and cause infection. The client should use fresh saline every time they suction their tracheostomy.
Correct Answer is A
Explanation
“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.
The other choices are wrong because:
Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.
Choice C. “Don’t think like that.
It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.
Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.
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