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 D
Explanation
The nurse should expect to find hyperkalemia in the medical record of a client who has sustained a full- thickness burn and is in the emergent phase of the burn. This is due to the release of potassium from damaged cells into the bloodstream.
a) Hypernatremia is not a common finding in the emergent phase of a burn.
b) Hypercalcemia is not a common finding in the emergent phase of a burn.
c) Hypermagnesemia is not a common finding in the emergent phase of a burn.
Correct Answer is A
Explanation
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates severe respiratory distress or failure. In this situation, the client's oxygenation is compromised, and immediate intervention is needed to ensure an open and unobstructed airway. The nurse should prioritize ensuring the client has a patent airway by assessing for any airway obstruction and taking appropriate measures to clear the airway if necessary. This may involve techniques such as the head tilt-chin lift or jaw thrust maneuver.
While administering oxygen, checking the client's pulse rate, and placing a pulse oximeter on the client's finger are all important interventions in managing respiratory distress, the first and most critical step is to establish a patent airway. Without a clear airway, the client's oxygenation cannot be adequately addressed, and other interventions may be ineffective. Once the airway is secured, the nurse can proceed with providing oxygen, assessing the client's vital signs, and monitoring oxygen saturation using a pulse oximeter.
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