Nokea
A clear liquid diet is ordered for an adult following surgery. All of the following are on the client's tray. Which should be removed by the nurse?
- A. Ice cream
- B. Beef broth
- C. Apple juice
- D. Iced tea
Correct Answer: A
Rationale: Ice cream is not a clear liquid, as it contains dairy solids, and must be removed from a clear liquid diet tray.
You may also like to solve these questions
The nurse is observing a certified nursing assistant (CNA) caring for a client who has AIDS. Which action, if observed, is not correct?
- A. The CNA wears gloves when cleaning the client after an episode of fecal incontinence.
- B. The CNA uses chlorine bleach to wipe up blood after the client cut himself shaving.
- C. The CNA is observed giving the client a back rub without gloves on.
- D. The CNA wears a mask whenever entering the client's room.
Correct Answer: C
Rationale: Standard precautions require gloves during contact with non-intact skin or bodily fluids, including during a back rub for an AIDS client, to prevent transmission. Gloves for incontinence, bleach for blood, and masks (if indicated) are appropriate.
A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication?
- A. I can take it whenever I feel upset.
- B. I should not take this with anything but water.
- C. I guess I need to stop drinking white wine.
- D. This medication will help me forget and go on.
Correct Answer: C
Rationale: Alcohol, including white wine, potentiates Xanax’s sedative effects, increasing risks. Avoiding it shows understanding. Options A, B, and D are incorrect.
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
- A. I have constant blurred vision.
- B. I can't see on my left side.
- C. I have to turn my head to see my room.
- D. I have specks floating in my eyes.
Correct Answer: C
Rationale: I have to turn my head to see my room. Intraocular pressure becomes elevated, producing a progressive loss of the peripheral visual field in the affected eye.
The nurse observes the student nurse enter wearing a gown, gloves, and a mask.
The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
- A. An infant diagnosed with respiratory syncytial virus.
- B. A young child with a wound infected with S aureus.
- C. A teenager diagnosed with toxic shock syndrome.
- D. A teenager diagnosed with rubella (German measles).
Correct Answer: D
Rationale: Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct-droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open