The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Remind the client no milk or creamer can be added to the coffee.

Determine which member of the nursing staff brought the cup of coffee to the client.

Remove the coffee from the tray, advising the client that it is not included in the diet.

Consult with the dietitian to learn if the client is allowed to drink coffee.

Answer and Explanation

The Correct Answer is C

C. A clear liquid diet typically includes transparent or translucent liquids that are easy to digest and leave minimal residue in the gastrointestinal tract. Coffee, especially if it contains milk or creamer, is not considered a clear liquid and is not usually permitted on a clear liquid diet.

A. Reminding the client no milk or creamer can be added to the coffee may be appropriate for clients on other dietary restrictions but does not address the issue of coffee not being part of a clear liquid diet.

B. Determining which member of the nursing staff brought the cup of coffee to the client is not necessary unless there is a need to investigate a specific incident or identify potential lapses in care.

D. Consulting with the dietitian to learn if the client is allowed to drink coffee may be appropriate for clarifying dietary restrictions or allowances, but in the context of a clear liquid diet, coffee is typically not permitted regardless of the dietitian's input.

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Correct Answer is B

Explanation

B. A bedside commode allows the client to sit comfortably and maintain independence while toileting. Using a commode chair near the bed reduces the need for bedpan use and promotes mobility.

A. Reassurance is important, but simply reassuring the client without addressing their specific concerns or providing practical solutions may not fully address the issue.

C. Elevating the head of the bed can help with using the bed pan but does not include the other plan of care as a bedside commode would.

D. While positioning the bedpan on the chair may provide an alternative option for the client, it may not be the most practical solution, especially if the client is able to use the bedpan while in bed.

A. Placing a client in restraints without having a healthcare provider's order. B. Informing a client that the medication being administered is a vitamin. C. Enlisting security personnel to assist with restraining the client. D. Administering the medication to a client behind a closed curtain.

Correct Answer is A

Explanation

A. A tort is a civil wrong that causes harm to another individual, and placing a client in restraints without having a healthcare provider's order is an example of a tort called false imprisonment.
B. Informing a client that the medication being administered is a vitamin. Providing false information about the nature of the medication could lead to harm or prevent the client from making an informed decision about their care. However, it does not constitute a tort

C. Enlisting security personnel to assist with restraining the client is not inherently a tort.

D. Administering medication behind a closed curtain may raise concerns about privacy and confidentiality, but it does not inherently constitute a tort.

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The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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