A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

Yogurt with fruit

Pudding

Cooked vegetables

Bananas

Answer and Explanation

The Correct Answer is B

A. Yogurt with fruit:

While yogurt with fruit is a soft and easily digestible option, it is not representative of a progression from a clear liquid diet to a full liquid diet. Yogurt is typically included in a full liquid diet, but the addition of fruit may introduce solid particles. The transition from clear to full liquids usually involves avoiding solid or textured foods.

B. Pudding:

Pudding is a suitable choice that aligns with the progression from a clear liquid diet to a full liquid diet. Pudding is a smooth and creamy food, making it appropriate for someone transitioning from clear liquids. It provides a source of calories and is easy to swallow, meeting the criteria for a full liquid diet.

C. Cooked vegetables:

Cooked vegetables are not part of a full liquid diet. While they are a healthy food choice, they are too textured for someone transitioning from a clear liquid diet. Full liquid diets focus on foods that are liquid at room temperature or become liquid when they reach body temperature.

D. Bananas:

Bananas are a soft and easily digestible fruit, but they are not typically included in a full liquid diet. The texture of bananas may be too thick for someone progressing from a clear liquid diet, and they are not considered a liquid or a food that becomes liquid at room temperature.

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Correct Answer is A

Explanation

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.

A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Keep the client's room temperature at 18° C (64.4" F). D. Provide the client with a night light.

Correct Answer is D

Explanation

A. Elevate full-length side rails on both sides of the client's bed:

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

B. Place the bedside table 0.9 m (3 feet) away from the bed:

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

C. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

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A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

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Correct Answer is D

Explanation

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