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. Smoking is a significant risk factor for the development of cardiovascular disease, as it contributes to the narrowing and hardening of the arteries, increases blood pressure, reduces oxygen supply to tissues, and promotes the formation of blood clots.

A. Chronic stress can contribute to cardiovascular disease by raising blood pressure, increasing heart rate, and promoting inflammation.

C. Regular physical activity is crucial for cardiovascular health. It helps strengthen the heart muscle, lower blood pressure, improve cholesterol levels, control weight, and reduce stress.

D. A low-fat diet, particularly one that is high in fruits, vegetables, whole grains, and lean proteins, can help lower cholesterol levels, reduce blood pressure, and manage weight, all of which are important for heart health.

Although A, C, D play a role in preventing cardiovascular disease, smoking is the major risk factor for cardiovascular disease.

A. Assess capillary refill distal to the restraints. B. Verify that the restraints can be quickly released. C. Replace the nasogastric tube. D. Reinsert the peripheral IV catheter.

Correct Answer is B

Explanation

B. When applying restraints, ensuring that they can be quickly released is essential for maintaining the safety and well-being of the client. This is especially important in cases where restraints are used to prevent harm or injury to the client, as they should only be used as a last resort and for the shortest duration necessary.

A. Checking capillary refill provides valuable information about peripheral perfusion and the adequacy of blood flow to the extremities. However, ensuring the restraints can be released easily is more crucial.

C. While replacing the nasogastric tube may be necessary if it has been removed, it's not the most immediate concern after applying wrist restraints. The priority is to ensure the safety and comfort of the patient with the restraints in place.

D. Reinserting the peripheral IV catheter may be necessary if it has been dislodged. However, it's not the most critical action immediately after applying wrist restraints.

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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?

Nursing Test Bank

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