A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings, and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

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Question 1 of 5

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings, and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

Correct Answer: C

Rationale: The client’s caregiver washes out the feeding bag with warm water once every 24 hr. Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination.

Question 2 of 5

A nurse is assessing an older client’s risk for falls. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select ONE that does not apply)

Correct Answer: A

Rationale: Pupil clarity, Visual fields, Visual acuity.

Question 3 of 5

A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Correct Answer: D

Rationale: A stool test for occult blood detects hidden blood, indicating potential GI bleeding. Bacteria (A) and parasites (B) require different tests. Steatorrhea (C) is assessed via a fecal fat test.

Question 4 of 5

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Correct Answer: D

Rationale: A pillow provides comfort and support. Elevating (A) hinders movement. Folding arms (B) isn’t standard. Asking another nurse (C) is unclear.

Question 5 of 5

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C Which assessment is the priority?

Correct Answer: B

Rationale: C4 trauma can impair the phrenic nerve, which innervates the diaphragm. Respiratory failure is a life-threatening risk, making respiration the priority assessment over pain, temperature, or blood pressure.

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