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 D

Explanation

D. This area is commonly used for LMWH injections due to its high vascularity and absorption rate. Injecting at least 2 inches away from the umbilicus helps minimize the risk of injury to the umbilical vessels and ensures proper absorption of the medication.

A. Massaging the injection site is not recommended after administering LMWH because it can increase the risk of bruising, bleeding, or tissue damage.

B. LMWH injections are typically administered in the abdomen, with sites rotated within the same area. While rotating between the abdomen and gluteal areas may be appropriate for some medications, LMWH is generally administered in the abdomen only.

C. If you expel the air bubbles before injecting, you might inadvertently expel a small amount of insulin along with the air. This could result in receiving less insulin than intended.

A. "I'm sorry, but your child's medical information is none of your business." B. "I can only give medical information to your child because they are legally an adult." C. "The healthcare provider will share this information with you." D. "I can give you those results as soon as I get them back from the lab."

Correct Answer is B

Explanation

"I'm sorry, but your child's medical Information is none of your business."This response is confrontational and dismissive, and it doesn't effectively address the parents' concerns. It's important to maintain professionalism and respect even in challenging situations.

"I can only give medical Information to your child because they are legally an adult."This response respects the minor's emancipated status and acknowledges that, legally, the nurse can only disclose medical information to the emancipated minor themselves. It upholds the principles of patient confidentiality and autonomy while also providing clear and accurate information to the parents about their limitations regarding access to their child's medical information.

"The healthcare provider will share this information with you," could potentially mislead the parents because it implies that the healthcare provider will provide them with the information directly. However, if the minor is legally emancipated, the healthcare provider would still be bound by confidentiality laws and would only be able to disclose information to the minor themselves unless there are extenuating circumstances or legal exceptions.

I can give you those results as soon as I get them back from the laboratory."While this response offers to provide information, it doesn't address the issue of confidentiality or the parents' role in receiving the information. It's also not accurate to promise the results directly without involving the healthcare provider, who is responsible for interpreting and discussing the results with the patient and family.

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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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