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

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

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

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

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

Answer and Explanation

The Correct Answer is C

A. Removing the coffee might not be necessary if coffee is allowed on a clear liquid diet. The client may have been provided with the coffee based on dietary guidelines.
B. Determining which staff member brought the coffee does not address the immediate need to ensure dietary guidelines are followed.
C. On a clear liquid diet, coffee is typically allowed as long as it is consumed without milk or cream. Advising the client about this restriction ensures adherence to the diet and proper management of dietary restrictions.
D. Consulting with the dietician is important for confirming dietary guidelines but addressing the immediate situation with the client’s understanding of their diet is a more direct action.

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Correct Answer is B

Explanation

A. Stopping suctioning may not be necessary if the oxygen saturation is stable and within acceptable limits. The key is to ensure that the suctioning procedure is not adversely affecting oxygenation.
B. Repositioning the pulse oximeter clip is a good practice to ensure accurate readings, especially if there is any concern about the reliability of the current measurement. An accurate oxygen saturation reading is essential for assessing the impact of the suctioning procedure.
C. Completing the suctioning procedure may be appropriate if the oxygen saturation is stable. However, it’s important to ensure that the oxygen saturation readings are accurate and reliable before continuing.
D. Applying an oxygen mask may be necessary if the client's oxygen saturation drops, but there is no indication that the oxygen saturation has decreased. Repositioning the oximeter clip is a more immediate step to ensure accurate readings.

A. Determine if the expected outcomes were realistic. B. Review related professional standards of care. C. Obtain current client data to compare with expected outcomes. D. Modify the nursing interventions to achieve the client's goals.

Correct Answer is C

Explanation

A. Determining if the expected outcomes were realistic is important but comes after comparing the actual client data with the expected outcomes. If the outcomes were unrealistic, it would be identified during this comparison.
B. Reviewing professional standards of care is important for ensuring that care meets quality standards but is not the immediate next step after reviewing the expected outcomes.
C. Obtaining current client data to compare with expected outcomes is the next step to assess whether the client’s condition has improved, worsened, or remained the same. This comparison is crucial for evaluating the effectiveness of the nursing care.
D. Modifying nursing interventions should be done based on the evaluation of client data and outcomes. It is a subsequent step after assessing whether the outcomes have been met.

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The nurse observes that 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

Naxlex Comprehensive Predictor Exams

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is C

Explanation

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