You are providing care for a patient on a clear liquid diet. You know your teaching about the clear liquid diet has been effective when the patient chooses which of the following meals?

Chicken noodle soup with Pedialyte and tea

Chicken broth with Jell-O and coffee.

Vegetable broth with yogurt and apple juice.

Tomato soup with a popsicle and water

Answer and Explanation

The Correct Answer is B

A. Chicken noodle soup with Pedialyte and tea: Chicken noodle soup contains solids (noodles, vegetables, meat), which are not allowed on a clear liquid diet.

B. Chicken broth with Jell-O and coffee: Broth and Jell-O are transparent and fully liquid at room temperature, meeting clear liquid diet guidelines. As long as it is without milk or cream, coffee can be included in the diet.

C. Vegetable broth with yogurt and apple juice: Yogurt is not a clear liquid. Apple juice is okay if filtered, but yogurt makes the meal incorrect.

D. Tomato soup with a popsicle and water: Tomato soup is not clear, as it is opaque and pureed, which disqualifies it from the clear liquid diet.

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Correct Answer is A

Explanation

A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.

B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.

C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.

D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.

A. Slough tissue is present. B. Adipose tissue is present. C. Fascia tissue is present. D. Undermining is present.

Correct Answer is C

Explanation

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

You are providing care for a patient on a clear liquid diet. You know your teaching about the clear liquid diet has been effective when the patient chooses which of the following meals?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Correct Answer is C

Explanation

During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report this findings to the provider?

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Which of the following clients should avoid the use of cold therapy?

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