The patient has just been started on 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

Choice A reason: Clostridium difficile is a bacterium that can cause severe diarrhea, but it is usually associated with recent antibiotic use or hospitalization. The immediate onset of diarrhea after starting enteral feeding points to a more direct cause related to the feeding itself.

Choice B reason: Antibiotic therapy can lead to diarrhea by disrupting the normal gut flora, but the scenario describes an immediate response to enteral feeding, making this option less likely as the primary cause.

Choice C reason: This is the correct answer. Formula intolerance is a common cause of diarrhea soon after starting enteral feeding. The patient's gastrointestinal system may be reacting to the components of the formula, leading to symptoms like diarrhea.

Choice D reason: Bacterial contamination can cause diarrhea, but it generally does not result in immediate symptoms right after starting enteral feeding. Proper handling and preparation of enteral feeds are essential to prevent contamination, but the rapid onset in this scenario suggests formula intolerance.

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Correct Answer is C

Explanation

Choice A reason: A WBC count of 8,000/mm³ falls within the normal range (4,000-11,000/mm³) and does not indicate a specific risk for delayed wound healing. It helps assess the immune response but is not a direct marker for nutrition or tissue repair.

Choice B reason: A hemoglobin level of 16 g/dL is within the normal range (13.8-17.2 g/dL for men, 12.1-15.1 g/dL for women) and indicates adequate oxygen-carrying capacity. While essential for overall health, it does not directly correlate with the risk of delayed wound healing in this context.

Choice C reason: This is the correct answer. Serum albumin levels are a marker of nutritional status. A level of 3.2 g/dL is on the lower side of the normal range (3.5-5.0 g/dL) and indicates potential malnutrition, which can impair wound healing by limiting the availability of necessary proteins and nutrients for tissue repair.

Choice D reason: An INR (International Normalized Ratio) of 0.9 is within the normal range (0.8-1.2) and reflects normal blood clotting. While important for understanding coagulation status, it does not indicate a direct risk for delayed wound healing related to nutrition or protein levels.

A. neostigmine B. naloxone C. protamine D. flumazenil

Correct Answer is B

Explanation

Choice A reason: Neostigmine is an acetylcholinesterase inhibitor used to treat myasthenia gravis and is not relevant to the administration of morphine. It does not act as an antidote for opioid overdose.

Choice B reason: This is the correct answer. Naloxone is an opioid antagonist that can reverse the effects of opioid overdose, including morphine. It is essential to have naloxone available in case the client experiences respiratory depression or other severe opioid side effects.

Choice C reason: Protamine is used to reverse the effects of heparin, an anticoagulant. It has no role in the management of opioid overdose and is not necessary to have available when administering morphine.

Choice D reason: Flumazenil is an antidote for benzodiazepine overdose. While useful in specific cases, it does not counteract the effects of opioids like morphine and is therefore not the appropriate medication to have on hand in this scenario.

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The patient has just been started on 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

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Correct Answer is B

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