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?

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

A: Auscultation, or listening for air injected into the tube, is not a reliable method for verifying feeding tube placement. It can lead to false positives and does not confirm the tube’s location accurately.

B: X-ray is the gold standard for verifying feeding tube placement. It provides a clear image of the tube’s position, ensuring it is correctly placed in the stomach or small intestine, reducing the risk of complications.

C: Aspiration of contents can help verify placement by checking the appearance and pH of the aspirate. However, it is not as definitive as an X-ray and can sometimes be inconclusive.

D: pH testing of aspirate can indicate whether the tube is in the stomach (acidic pH) or intestines (less acidic). While useful, it is not as reliable as an X-ray for confirming placement.