A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention?
Providing a ham and cheese sandwich to a client who follows a kosher diet
Giving peanut butter to a client who was prescribed a mechanical soft diet
Offering ginger ale to a client who is a member of the Mormon faith
Serving ice cream to a client who prescribed a full-liquid diet
The Correct Answer is A
A. Providing a ham and cheese sandwich to a client who follows a kosher diet: Kosher dietary laws prohibit pork and require specific food preparation. Giving a ham sandwich directly violates the client’s religious dietary restrictions and requires immediate correction and staff education to respect cultural and religious practices.
B. Giving peanut butter to a client who was prescribed a mechanical soft diet: A mechanical soft diet includes foods that are easy to chew and swallow. While crunchy peanut butter would be restricted, smooth peanut butter is typically allowed as it does not require significant mastication.
C. Offering ginger ale to a client who is a member of the Mormon faith: Ginger ale is nonalcoholic and caffeine-free options are usually available. Serving ginger ale is generally consistent with Mormon dietary restrictions, which prohibit alcohol and caffeinated beverages, so this does not require intervention.
D. Serving ice cream to a client who prescribed a full-liquid diet: Ice cream is considered a full-liquid food and is consistent with this diet order. It does not violate dietary guidelines, so no intervention is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should verify the identity of anyone who wants to remove your baby from the room.": Parents should confirm the identity and role of anyone attempting to take the newborn to prevent abduction or misidentification. Verifying identification badges and following hospital protocols for infant security is a critical safety measure in the maternal-newborn unit.
B. "You can leave your baby in your room while you walk in the hallway.": Newborns should never be left unattended, even briefly, due to the risk of falls, accidental injury, or abduction. Continuous supervision by a parent or staff member is required at all times.
C. "Your baby should have one identification band on either their right arm or right leg.": Standard newborn safety procedures require two identification bands—one on the wrist and one on the ankle—to ensure correct identification. A single band is insufficient for reliable infant security.
D. "You can leave the unit with your baby as long as you notify the nurse.": Leaving the unit with a newborn without following strict security protocols, including escort and verification, is prohibited. Unauthorized movement of the infant could compromise safety and breach hospital security policies.
Correct Answer is ["A","B","E","F","G"]
Explanation
Rationale for correct choices:
• Weight: The child’s weight increased from 9.5 kg on day 2 to 10.2 kg on day 3, surpassing the admission weight of 10 kg. This indicates successful rehydration and restoration of fluid balance. Weight gain is a reliable objective marker of improvement in pediatric dehydration.
• Bowel pattern: The child’s stools changed from six watery stools on day 2 to two formed stools on day 3. This reflects resolution of diarrhea and recovery of gastrointestinal function. Normalization of bowel movements indicates that electrolyte and fluid losses have been addressed effectively.
• Urine specific gravity: Urine specific gravity decreased from 1.031 on admission to 1.018 on day 3. This reflects improved hydration status and kidney perfusion, as urine is less concentrated. Monitoring urine concentration helps evaluate the effectiveness of fluid replacement therapy.
• Skin turgor: Skin turgor improved from 2 seconds to less than 1 second and appears consistent with the child’s baseline. This indicates restored hydration and effective fluid therapy. Normal skin turgor demonstrates recovery from extracellular fluid deficit.
• Heart rate: The heart rate decreased from a tachycardic 116/min on Day 2 to 100/min on Day 3. A stable, lower heart rate indicates that the circulatory volume is adequate and the heart no longer needs to overcompensate for low blood volume.
Rationale for incorrect findings:
• Sodium level: Sodium remained within normal range (138 mEq/L), so while stable, it does not specifically indicate improvement beyond baseline.
• Respiratory rate: Respiratory rate remained mildly elevated at 26 breaths/minute; it shows stability but does not directly indicate recovery from dehydration.
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