the nurse requests a meal tray for a client who follows mormon beliefs and who is on a clear liquid diet following abdominal surgery which menu items
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Adult Health 1 HESI

1. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)

Correct answer: A

Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.

2. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

Correct answer: A

Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.

3. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?

Correct answer: B

Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.

4. A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

Correct answer: A

Rationale: The correct answer is A. The patient should be placed near the nurse’s station if confused to allow close monitoring by the staff. To help improve serum sodium levels, water intake is restricted, so a patient with hyponatremia should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia, so telemetry for this purpose is unnecessary. Placing a confused patient in a semi-private room could be disruptive to the other patient. Additionally, the patient needs sodium replacement, not a low-salt diet.

5. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?

Correct answer: A

Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.

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