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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A: A simple face mask provides a moderate concentration of oxygen but does not have a one-way valve to deliver the highest concentration of oxygen.

B: A Venturi mask delivers a precise concentration of oxygen but is not designed to provide the highest concentration of oxygen with a one-way valve.

C: A non-rebreather mask is the correct choice. It has a one-way valve that prevents exhaled air from re-entering the bag, allowing the delivery of the highest concentration of oxygen to the client.

D: A partial rebreather mask provides a high concentration of oxygen but does not have a one-way valve, making it less effective than a non-rebreather mask for delivering the highest oxygen concentration.

A. “I better chew my medication first for faster distribution.” B. “I should let the medication dissolve completely.” C. “I can only drink water, not juice, with this medication.” D. “I will place the medication between my cheek and gum.”

Correct Answer is B

Explanation

A: Chewing sublingual medication is incorrect. Sublingual medications are designed to dissolve under the tongue for rapid absorption into the bloodstream.

B: Letting the medication dissolve completely is correct. This ensures that the medication is absorbed properly and works effectively.

C: There is no restriction on drinking juice with sublingual medication unless specified by the healthcare provider. This statement does not indicate a clear understanding of sublingual administration.

D: Placing the medication between the cheek and gum is incorrect for sublingual medications. This method is used for buccal medications, not sublingual ones.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives an order from the provider for a client requiring the highest oxygen concentration with a one-way valve. What type of mask should the nurse apply to the client?

Correct Answer is C

Explanation

A nurse teaches the patient about the prescribed sublingual medication. Which statement by the patient indicates teaching by the nurse is successful?

Correct Answer is B

Explanation

A patient refuses medication. Which is the nurse’s first action?

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client’s wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission (Normal BUN 10-20)?

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that intestinal function is returning?

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?