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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 themostlikely cause of the diarrhea?
- A. Antibiotic therapy
- B. Clostridium difficile
- C. Formula intolerance
- D. Bacterial contamination
Correct Answer: C
Rationale: The correct answer is C: Formula intolerance. When a patient develops diarrhea shortly after starting enteral feeding, formula intolerance is the most likely cause. This can occur due to the patient's inability to tolerate certain ingredients in the formula, leading to gastrointestinal upset. Antibiotics (choice A) and Clostridium difficile (choice B) typically take longer to cause diarrhea. Bacterial contamination (choice D) would usually result in more severe symptoms beyond just diarrhea. In this scenario, formula intolerance is the most logical explanation for the immediate onset of diarrhea after starting enteral feeding.
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The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
- A. Measuring capillary blood glucose level
- B. Measuring nasoenteric tube for insertion
- C. Measuring pH in gastrointestinal aspirate
- D. Measuring the patient’s risk for aspiration
Correct Answer: A
Rationale: The correct answer is A because measuring capillary blood glucose level is a task that can be safely delegated to nursing assistive personnel. This task is within their scope of practice and does not require specialized nursing knowledge. Nursing assistive personnel can perform this task accurately with proper training and supervision.
Incorrect choices:
B: Measuring nasoenteric tube for insertion requires specialized training and assessment skills that nursing assistive personnel may not possess.
C: Measuring pH in gastrointestinal aspirate involves interpretation and clinical judgment that should be done by a licensed nurse.
D: Measuring the patient's risk for aspiration involves critical thinking and assessment skills that are beyond the scope of nursing assistive personnel.
A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
- A. Cleanse the skin surrounding the suprapubic tube.
- B. Inform the urologist of this finding.
- C. Remove the suprapubic tube and apply a wet-to-dry dressing.
- D. Administer antispasmodic drugs as ordered.
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage.
Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?
- A. A referral for a mammogram
- B. Instructions about breast self-examination (BSE)
- C. A referral to a surgeon
- D. A referral to a support group
Correct Answer: A
Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed.
B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals.
C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer.
D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.
While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justified in presuming that this patient has what medical condition?
- A. Bacterial vaginosis
- B. Human papillomavirus (HPV)
- C. Candidiasis
- D. Toxic shock syndrome (TSS)
Correct Answer: C
Rationale: Rationale for Correct Answer (C): The nurse can presume the patient has candidiasis since miconazole is commonly used to treat fungal infections like vaginal yeast infections caused by Candida. This medication works by stopping the growth of the fungus. Therefore, the patient's use of miconazole indicates a probable diagnosis of candidiasis.
Summary of Incorrect Choices:
A (Bacterial vaginosis): Miconazole is not used to treat bacterial infections like bacterial vaginosis, which is caused by an imbalance of bacteria in the vagina.
B (HPV): Miconazole is not used to treat viral infections like HPV, which is a sexually transmitted infection caused by certain types of human papillomavirus.
D (TSS): Miconazole is not used to treat toxic shock syndrome, which is a severe complication of certain bacterial infections and is not typically associated with miconazole use.
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
- A. Oral temperature of 100F
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of 1 pound since yesterday
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure.
Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition.
Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario.
Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.