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
Explanation
Choice A rationale
Edema in the fingers and hands can affect the accuracy of a pulse oximeter reading. The swelling can interfere with the probe’s ability to detect the blood flow properly, leading to a falsely low oxygen saturation reading.
Choice B rationale
A capillary refill time of 2 seconds is considered normal and does not typically affect the accuracy of a pulse oximeter reading.
Choice C rationale
Blood pressure of 142/88 mm Hg, while elevated, does not directly impact the accuracy of a pulse oximeter reading.
Choice D rationale
A radial pulse volume of 3+ indicates a strong pulse, which should not interfere with the accuracy of a pulse oximeter reading.
Correct Answer is B
Explanation
Choice A rationale
Advising the UAP to hold the thermometer securely in place for a full three minutes is unnecessary and may cause discomfort to the client. Tympanic thermometers typically provide rapid temperature readings within a few seconds.
Choice B rationale
Positive reinforcement is important for encouraging and motivating staff, it should be used appropriately. In this case, the UAP is performing the procedure correctly.
Choice C rationale
Demonstrating the correct technique for pulling the client’s auricle down and back is incorrect because the UAP is using the correct technique. For adults, the auricle should be pulled up and back.
Choice D rationale
Reminding the UAP to lubricate the thermometer before gently inserting it in the ear is not necessary for tympanic thermometers. The primary issue in this scenario is the incorrect technique for positioning the client’s auricle, so reminding about lubrication is not the most relevant intervention.