You are providing care for a patient on a clear liquid diet. You know your teaching about the clear liquid diet has been effective when the patient chooses which of the following meals?
Chicken noodle soup with Pedialyte and tea
Chicken broth with Jell-O and coffee.
Vegetable broth with yogurt and apple juice.
Tomato soup with a popsicle and water
The Correct Answer is B
A. Chicken noodle soup with Pedialyte and tea: Chicken noodle soup contains solids (noodles, vegetables, meat), which are not allowed on a clear liquid diet.
B. Chicken broth with Jell-O and coffee: Broth and Jell-O are transparent and fully liquid at room temperature, meeting clear liquid diet guidelines. As long as it is without milk or cream, coffee can be included in the diet.
C. Vegetable broth with yogurt and apple juice: Yogurt is not a clear liquid. Apple juice is okay if filtered, but yogurt makes the meal incorrect.
D. Tomato soup with a popsicle and water: Tomato soup is not clear, as it is opaque and pureed, which disqualifies it from the clear liquid diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.
B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.
C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.
D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.
Correct Answer is C
Explanation
A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.
B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.
C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.
D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.
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