The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?
Clostridium difficile
Antibiotic therapy
Formula intolerance
Bacterial contamination
The Correct Answer is C
A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.
B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.
C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.
D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Administering the medication and monitoring the patient frequently is not appropriate because phenytoin is not indicated for pain management.
B: Refusing to give the medication and notifying the nurse supervisor is a step in the right direction, but the nurse should also seek clarification from the health care provider.
C: Giving the patient hydromorphone without clarification is not appropriate. The nurse must verify the order with the health care provider.
D: Calling the health care provider to clarify the order is the correct action. This ensures that the correct medication is administered as intended.
Correct Answer is D
Explanation
A: Placing the head of the client’s bed in the flat position is not the appropriate first action. While it may help reduce strain on the abdominal area, it does not address the immediate issue of the exposed bowel.
B: Gently reinserting the bowel back into the client’s wound is not recommended. This action could cause further injury or introduce infection. The nurse should avoid manipulating the exposed bowel.
C: Positioning the client on his left side does not directly address the issue of the exposed bowel. While it may help with comfort, it does not provide the necessary protection for the exposed tissue.
D: Applying moistened sterile gauze to the site is the correct action. This helps protect the exposed bowel from contamination and keeps it moist, which is crucial to prevent tissue damage. The nurse should then notify the surgeon immediately for further instructions.
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