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 A
Explanation
A: Providing the client with a diet high in protein is essential for maintaining skin integrity. Protein is crucial for tissue repair and regeneration, which helps prevent skin breakdown and promotes healing of existing wounds.
B: Repositioning the client every 3 hours is less effective than the recommended every 2 hours. Frequent repositioning helps to relieve pressure on vulnerable areas and prevent pressure injuries.
C: Massaging bony prominences is not recommended as it can cause further damage to already fragile skin and underlying tissues. Gentle handling and avoiding pressure on these areas are more appropriate.
D: Applying cornstarch to keep the skin dry is not advisable as it can lead to skin irritation and breakdown. Instead, using moisture-wicking products and maintaining proper skin hygiene are better practices.
Correct Answer is D
Explanation
A: Hypotension is not an early sign of hypoxemia. It can occur in severe cases but is not typically an initial indicator.
B: Nausea is not a common sign of hypoxemia. It may occur due to other factors but is not directly related to low oxygen levels.
C: Dysphagia, or difficulty swallowing, is not a sign of hypoxemia. It is related to swallowing disorders rather than oxygen levels.
D: Confusion is an early sign of hypoxemia. Low oxygen levels can affect brain function, leading to confusion and other cognitive changes.
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