A nurse is caring for a client who is postoperative and has a prescription for a full liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

Apple juice

Cream of rice cereal

Vanilla yogurt

Scrambled eggs

Answer and Explanation

The Correct Answer is D

A. Apple juice: Apple juice is appropriate for a full liquid diet.
B. Cream of rice cereal: Cream of rice cereal is suitable for a full liquid diet as it can be made to a thin consistency.
C. Vanilla yogurt: Vanilla yogurt is allowed on a full liquid diet.
D. Scrambled eggs: Scrambled eggs are not considered part of a full liquid diet as they are a solid food.

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Correct Answer is B

Explanation

A. Massage the injection site after administration of the medication. Massaging the site after heparin injection can cause bruising and should be avoided.
B. Inject the medication into the abdomen above the level of the iliac crest: This is the recommended site for subcutaneous heparin injections.
C. Use a 1-inch needle to inject the medication. A shorter needle (5/8 inch) is typically used for subcutaneous injections, not a 1-inch needle.
D. Use a 22-gauge needle to inject the medication: A smaller gauge needle (25 to 27 gauge) is typically used for subcutaneous injections, not 22-gauge.

A. Purplish colored stoma B. No stool noted in the collection bag C. Edematous stoma D. Slight bleeding of the stoma site

Correct Answer is A

Explanation

A. Purplish colored stoma: A purplish colored stoma indicates compromised blood flow and possible necrosis, which is an emergency and must be reported immediately.
B. No stool noted in the collection bag: It is normal for there to be no stool in the collection bag 12 hours postoperatively as bowel function may not yet have resumed.
C. Edematous stoma: Edema of the stoma is common in the immediate postoperative period and usually subsides with time.
D. Slight bleeding of the stoma site: Slight bleeding at the stoma site can be normal immediately after surgery due to the manipulation of tissues.

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A nurse is caring for a client who is postoperative and has a prescription for a full liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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