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
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it is not the primary action that indicates an understanding of standard precautions. Standard precautions emphasize hand hygiene as the most critical step in preventing infection transmission.
Choice B rationale
Donning a face mask before administering the medication is not necessary for standard precautions in home settings. Face masks are typically used in healthcare settings to prevent the spread of respiratory infections, but they are not required for routine medication administration at home.
Choice C rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the spread of infections and is a critical step in ensuring safe injection practices.
Choice D rationale
Removing the needle before discarding used syringes is not recommended. The entire needle and syringe should be disposed of in a sharps container to prevent needlestick injuries and contamination.
Correct Answer is B
Explanation
Choice A rationale
Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality of the pain. Quality refers to the characteristics and nature of the pain, which cannot be captured by a numeric scale alone.
Choice B rationale
Asking the client to describe the pain is the best approach to assess the quality of the pain. This allows the client to provide detailed information about the pain’s characteristics, such as its nature, location, and any associated symptoms.
Choice C rationale
Observing body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain’s quality. Nonverbal cues are helpful but should be supplemented with the client’s verbal description.
Choice D rationale
Identifying effective pain relief measures is important for pain management but does not directly assess the quality of the pain. This step comes after understanding the pain’s characteristics.