The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery.
Which menu item(s) should the nurse request for this client? (Select all that apply).

Choice A rationale: Orange juice contains pulp and is not considered a clear liquid. A clear liquid diet is restricted to fat-free liquids and those that are transparent at room temperature.

Choice B rationale: Apple juice is a transparent liquid that remains liquid at room temperature. It provides carbohydrates and fluid without leaving residue in the gastrointestinal tract, fitting the clear liquid requirement.

Choice C rationale: Hot chocolate contains dairy or cocoa solids, making it an opaque liquid. It is excluded from a clear liquid diet and also contains caffeine, which Mormons typically avoid.

Choice D rationale: Chicken broth is a clear, fat-free liquid that provides electrolytes and hydration. It is an essential component of a clear liquid diet and does not violate any Mormon dietary restrictions.

Choice E rationale: Black coffee is a caffeinated beverage. The Word of Wisdom in Mormon belief prohibits the consumption of "hot drinks," specifically interpreted as coffee and tea, regardless of the diet type.

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.