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 ["A","C","E","G"]
Explanation
Choice A rationale
Measuring vital signs at 0800 is a standard practice in many healthcare settings to establish a baseline for the day.
Choice B rationale
Measuring vital signs at 1000 is not typically a standard time unless there is a specific clinical indication.
Choice C rationale
Measuring vital signs at 1200 helps monitor the client’s status around midday and can be important for assessing the effects of morning medications or treatments.
Choice D rationale
Measuring vital signs at 1400 is not typically a standard time unless there is a specific clinical indication.
Choice E rationale
Measuring vital signs at 1600 helps monitor the client’s status in the afternoon and can be important for assessing the effects of afternoon medications or treatments.
Choice F rationale
Measuring vital signs at 1800 is not typically a standard time unless there is a specific clinical indication.
Choice G rationale
Measuring vital signs at 2000 helps monitor the client’s status in the evening and can be important for assessing the effects of evening medications or treatments.
Correct Answer is A
Explanation
Choice A rationale
Having the client demonstrate prescribed wound care is the most effective method to evaluate the client’s understanding of self-care at home. This approach allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide immediate feedback and clarification as needed. Demonstration ensures that the client can correctly follow the wound care instructions, which is crucial for proper healing and preventing complications.
Choice B rationale
Asking the client if they understand after each instruction may not be effective, especially if the client is not comfortable expressing confusion or misunderstanding. This method relies on the client’s verbal confirmation, which may not accurately reflect their ability to perform the wound care tasks correctly.
Choice C rationale
Having an interpreter repeat the wound care instructions can help bridge the language barrier, but it does not allow for direct observation of the client’s ability to perform the necessary tasks. While the interpreter can ensure that the client understands the instructions, it does not provide the nurse with a way to assess the client’s practical skills.
Choice D rationale
Providing written instructions in the client’s native language can be helpful, but it does not allow the nurse to directly evaluate the client’s understanding and ability to perform the wound care tasks. Written instructions alone may not be sufficient for clients who have limited literacy or who may have difficulty following written directions.