A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?
The formula infusion rate of the feeding was too slow.
The formula was given immediately following removal from the refrigerator.
The feeding tube was partially obstructed during the infusion.
The client is experiencing delayed gastric emptying.
The Correct Answer is D
Delayed gastric emptying can cause diarrhea in a client with a gastrostomy tube.
The other options are not likely causes of diarrhea.
a) A slow formula infusion rate (option would not cause diarrhea.
b) Giving formula immediately following removal from the refrigerator (option b) may cause discomfort but not diarrhea.
c) A partially obstructed feeding tube (option c) would slow down the infusion rate and would not cause diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale:
- While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
- Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
- A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).
Choice B rationale:
- Sterile gloves are not routinely required for contact isolation precautions.
- They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
- For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.
Choice C rationale:
- Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
- This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
- Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.
Choice D rationale:
- Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
- Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.
Correct Answer is A
Explanation
a. Giving broad openings
The nurse is using the therapeutic technique of giving broad openings. This technique encourages the client to freely express themselves and choose the focus of the conversation. By asking, "What has been happening with you today?" the nurse is inviting the client to share their thoughts, feelings, and experiences without imposing any specific topic or direction.
Explanation for the other options:
b. Focusing: Focusing is a therapeutic technique where the nurse directs the conversation to a specific topic or issue. In this scenario, the nurse is not guiding the client's response toward a particular area of discussion.
c. Reflecting: Reflecting is a therapeutic technique where the nurse repeats or paraphrases the client's words or feelings to demonstrate understanding and encourage further exploration. The nurse's statement in this scenario does not involve reflecting the client's words or feelings.
d. Seeking clarification: Seeking clarification is a therapeutic technique used to obtain more specific information or clear up any confusion. The nurse's statement in this scenario does not involve seeking clarification from the client.
In summary, by using a broad opening, the nurse allows the client to choose the focus of the conversation
and encourages them to share their experiences and concerns.
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