A client receives a clear liquid diet. The nurse removes which item from the client's tray? (Select all that apply)

Coﬀee with cream and sugar

Gelatin with applesauce

White grape juice

Bouillon that is reconstituted

Tea with sugar

Fruit ﬂavored ice pop

Answer and Explanation

Correct Answer : A,B

Choice A: Cream is not allowed on a clear liquid diet because it contains fat and protein, which make it opaque.
Choice B: While plain gelatin is allowed, applesauce is not because it is a puréed/semi-solid food, not a clear liquid.
Choice C: Clear fruit juices without pulp (such as apple juice, cranberry juice, and white grape juice) are permitted.
Choice D: Broth or bouillon is considered a clear liquid, as long as it does not contain solid particles.
Choice E: Tea is a clear liquid, and sugar does not change its clarity.

Choice F: Ice pops made from clear liquids (such as fruit juice without pulp) are permitted.

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Correct Answer is A

Explanation

A rectal temperature should not be taken if the client has bradycardia because stimulation of the vagus nerve during the insertion of the rectal thermometer can result in a further decrease in heart rate. Hypertension, tachypnea, and pyrexia are not contraindications for taking a rectal temperature.

A. Sits client on the side of the bed and assists the client to stand on right leg B. Rolls client to the right side and raises head to sit client on the side of the bed C. Lays client ﬂat on the left side and has client stand at the side of the bed D. Stands client from the side of the bed on the left leg and pivots client to the chair

Correct Answer is D

Explanation

This is because the client has right-sided paralysis and will not be able to bear weight on their right leg. By standing on their left leg and pivoting to the chair, the client can safely transfer from the bed to the wheelchair with the assistance of the nurse.

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A client receives a clear liquid diet. The nurse removes which item from the client's tray? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

Correct Answer is A

Explanation

A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

Correct Answer is D

Explanation

The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

The nurse provides care for a client with a poor appetite. Which action does the nurse take to enhance the client's nutritional intake?

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