A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
How many popsicles are available.
The color and flavor of gelatin used.
If the popsicles are completely frozen.
Whether they contain pulp or fruit.
The Correct Answer is C
Choice A rationale
Knowing how many popsicles are available is not relevant to the nurse’s assessment. The focus should be on the content and preparation of the popsicles to ensure they meet the clear liquid diet requirements.
Choice B rationale
The color and flavor of the gelatin used in the popsicles are not as important as ensuring the popsicles meet the clear liquid diet requirements. The nurse should focus on the preparation and content of the popsicles.
Choice C rationale
Ensuring the popsicles are completely frozen is important to adhere to the clear liquid diet recommendation. If the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child’s condition.
Choice D rationale
Whether the popsicles contain pulp or fruit is important to determine if they meet the clear liquid diet requirements. Popsicles with pulp or fruit do not qualify as clear liquids and could worsen the child’s condition.
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Correct Answer is C
Explanation
Choice A rationale
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The priority is to address the client’s comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position may help with breathing but does not directly address the issue of dry mucous membranes.
Choice C rationale
Keeping mucous membranes moist is crucial for the comfort of a terminally ill client who is mouth breathing and refusing anything to eat or drink. This intervention helps prevent dryness and discomfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client in this condition. The priority is to address the client’s comfort and hydration.
Correct Answer is B
Explanation
Choice A rationale
Assessing the strength of deep tendon reflexes is not the most important intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client’s reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.
Choice B rationale
This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client’s heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.
Choice C rationale
Observing the color and amount of urine is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client’s renal function and fluid balance, but these are not the priority assessments.
Choice D rationale
Comparing muscle strength bilaterally is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client’s neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.