An adult is on a clear liquid diet. Which food item can be offered/

Correct Answer: C

Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature. Rationale: 1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet. 2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet. 3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet. Summary: Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.

Correct Answer: B

Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco helps in removing dried blood when his tongue is bitten during a seizure, preventing infection and promoting oral hygiene. This is crucial in preventing complications and ensuring Mr. Franco's overall well-being. Choice A is incorrect because thirst is not directly related to mouth care, and increasing fluids intake would address dehydration more effectively. Choice C is incorrect as tactile stimulation may not necessarily hasten return to consciousness in this context. Choice D is incorrect as it refers to a different issue related to mouth breathing in comatose patients, which is not the immediate concern addressed by frequent mouth care in this scenario.

Correct Answer: B

Rationale: The correct answer is B because the problem-oriented approach involves focusing on the patient's presenting situation to identify the main issues and prioritize data collection. This step helps the nurse understand the immediate concerns and sets the direction for further assessment and interventions. Choice A is incorrect because completing questions in chronological order may not address the most urgent issues. Choice C is incorrect as accurate interpretations come after collecting relevant data. Choice D is incorrect as conducting an observational overview is part of the assessment process but not the first step in the problem-oriented approach.

Correct Answer: B

Rationale: The correct answer is B because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care. Incorrect choices: A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.