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","B","C","G","H"]
Explanation
Choice A rationale
Measuring vital signs at 1500 is crucial because the client is diaphoretic and flushed, indicating a potential change in condition that needs monitoring.
Choice B rationale
At 1600, blood glucose was obtained, and it is essential to measure vital signs to assess the client’s response to the insulin lispro given at 1800.
Choice C rationale
At 1800, the client ate 75% of his tray, and 4 units of insulin lispro were administered. Monitoring vital signs at this time helps evaluate the client’s metabolic response.
Choice G rationale
At 1400, the client voided clear, yellow urine. Measuring vital signs at this time provides a baseline for comparison with subsequent readings.
Choice H rationale
Measuring vital signs at 2000 ensures continuous monitoring and helps detect any late changes in the client’s condition.
Correct Answer is D
Explanation
Choice A rationale
While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.
Choice B rationale
Reporting the colleague’s actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.
Choice C rationale
Disposing of the copies may prevent further unauthorized access to patient information, but it does not address the issue of the colleague’s inappropriate handling of the records. It’s essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.