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. Power flushing with 60 mL might be too forceful and could potentially damage the bladder or catheter. It is important to use a gentle approach to avoid complications.
B. Slowly irrigating the catheter with saline using an infusion pump is appropriate for gently clearing the clots and sediment while maintaining a controlled flow rate. This method is effective in managing obstructions and maintaining catheter patency.
C. Clamping the catheter before irrigation is not recommended as it could lead to increased bladder pressure and discomfort. The goal is to maintain urine flow and prevent complications from clots.
D. Using a sterile syringe to irrigate with 20 mL normal saline may not be sufficient to clear larger clots and sediment. A controlled, slower irrigation method using an infusion pump is generally preferred.

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

Correct Answer is A

Explanation

A. Providing medical information to a family member who is not an approved interpreter may breach confidentiality and violate hospital policy. The nurse should ensure that communication is handled through approved channels to protect patient privacy.
B. While the healthcare provider will eventually share information with the client, the nurse should address the immediate need for proper communication with an approved interpreter.
C. This response is dismissive and does not address the issue of language barriers and the need for proper interpretation. It is important to handle language barriers professionally and respectfully.
D. The nurse should follow protocol for communication and interpretation, rather than making promises about when information will be provided.

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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

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Explanation

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Explanation

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