Nokea
A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.
- A. Tea
- B. Broth
- C. Gelatin
- D. Pudding
- E. Vegetable juice
- F. Pureed vegetables
Correct Answer: A,B,C
Rationale: A clear liquid diet consists of foods that are relatively transparent to light, and are clear and liquid at room and body temperature. These foods include such items as water, either regular or decaffeinated coffee or tea, bouillon, clear broth, gelatin, carbonated beverages, hard candy, lemonade, and popsicles. The incorrect food items are items that are allowed on a full liquid diet.
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Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
To improve the accuracy of client identification, the nurse must use at least two identifiers when providing care, treatment, or services. Which of the following are appropriate? Select all that apply.
- A. Room number.
- B. Bed number.
- C. Medical record number.
- D. Name band.
- E. Social security number.
Correct Answer: C,D,E
Rationale: Appropriate identifiers include medical record number, name band, and social security number, as they are unique to the client. Room and bed numbers are not reliable identifiers.
The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT). Which of the following interventions is most appropriate?
- A. Applying cold packs to the affected leg.
- B. Encouraging ambulation every hour.
- C. Administering heparin as ordered.
- D. Elevating the leg above heart level.
Correct Answer: C,D
Rationale: Heparin prevents clot extension in DVT, and elevating the leg reduces swelling and promotes venous return.
A client with a history of cirrhosis is admitted with jaundice. The nurse should include which of the following in the plan of care?
- A. Monitor for signs of bleeding.
- B. Encourage a high-fat diet.
- C. Administer vitamin C.
- D. Restrict protein intake.
Correct Answer: A
Rationale: Jaundice in cirrhosis indicates liver dysfunction, increasing bleeding risk due to impaired clotting factor production.
The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.