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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While consulting the palliative care team is appropriate for end-of-life care, it is essential first to clarify the client's understanding and wishes regarding "heroic measures" to ensure her preferences are fully understood and respected.
B. Setting up a family conference is important for discussing the client’s wishes with her loved ones, but this should occur after the nurse understands the client's specific desires.
C. The nurse should first discuss with the client what she means by "heroic measures" to ensure that her wishes are clearly understood. This conversation is essential to ensure that any subsequent actions, such as obtaining a DNR order, align with the client’s specific wishes.
D. A DNR prescription is an important step in respecting the client's wishes, but it should only be obtained after confirming exactly what the client means by "heroic measures" and ensuring that she fully understands the implications of a DNR order.
Correct Answer is C
Explanation
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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