An older client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory results are related to this finding, and should be reported to the health care provider immediately?

Glucose: 88 mg/dL

White Blood Cells (WBCs): 4000 (normal: 4,500- 11,000)

K+: 3.4 mEq/L

Na+: 154 mEq/L

Answer and Explanation

The Correct Answer is D

Choice A reason: This statement is false. Glucose: 88 mg/dL is a normal blood sugar level and does not indicate any problem with fluid or electrolyte balance¹.

Choice B reason: This statement is false. WBCs: 4000 is slightly below the normal range, but not significantly low. It may indicate a mild infection or inflammation, but not a serious fluid or electrolyte imbalance².

Choice C reason: This statement is false. K+: 3.4 mEq/L is slightly below the normal range, but not dangerously low. It may indicate a mild potassium deficiency, which can cause muscle weakness, but not restlessness or agitation.

Choice D reason: This statement is true. Na+: 154 mEq/L is above the normal range and indicates hypernatremia, or high blood sodium level. This can cause dehydration, confusion, restlessness, agitation, and seizures. It is a medical emergency that requires immediate treatment. Continuous tube feedings can increase the risk of hypernatremia if the formula is too concentrated or the fluid intake is inadequate⁵.

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Correct Answer is ["A","B","D","E","F"]

Explanation

Choice A reason: This statement is true. Assessing mental status and level of consciousness is an important consideration for this treatment, as morphine can cause sedation, confusion, and respiratory depression. The nurse should monitor the client's orientation, alertness, and responsiveness, and use a sedation scale to evaluate the degree of sedation.

Choice B reason: This statement is true. Assessing urine output frequently is an important consideration for this treatment, as morphine can cause urinary retention, which can lead to bladder distension, infection, or kidney damage. The nurse should measure the client's urine output and check for signs of bladder fullness or discomfort.

Choice C reason: This statement is false. Monitoring potassium levels is not an important consideration for this treatment, as morphine does not affect the blood potassium level. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Potassium imbalance can be caused by other factors, such as diuretics, vomiting, diarrhea, or acid-base disorders.

Choice D reason: This statement is true. Teaching the family that only the client can press the button for pain medication is an important consideration for this treatment, as PCA Pump allows the client to self-administer a preset dose of morphine within a specified time interval. The family should not press the button for the client, as this can result in overmedication, overdose, or addiction.

Choice E reason: This statement is true. Ensuring there is an order for Naloxone in case of overdose is an important consideration for this treatment, as Naloxone is an antidote that can reverse the effects of morphine in the event of an overdose. Naloxone can restore the client's breathing, blood pressure, and consciousness, and prevent death.

Choice F reason: This statement is true. Assessing CO2 levels is an important consideration for this treatment, as morphine can cause respiratory depression, which can lead to hypercapnia, or high blood carbon dioxide level. Hypercapnia can cause headache, drowsiness, confusion, and coma. The nurse should monitor the client's respiratory rate, depth, and rhythm, and use a capnograph or a blood gas analysis to measure the CO2 level.

Correct Answer is ["1.4"]

Explanation

The nurse should administer 1.4 mL of Heparin to the patient.

To calculate the number of milliliters (mL) the nurse should administer, we can use the following steps:

Step 1: Calculate the total amount of Heparin available in mL

Heparin concentration: 5,000 units per mL

Ordered Heparin dose: 7,000 units

Total mL of Heparin needed = Ordered dose / Heparin concentration

Total mL = 7,000 units / 5,000 units per mL = 1.4 mL

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An older client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory results are related to this finding, and should be reported to the health care provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client receiving morphine through a Patient Controlled Analgesia Pump (PCA Pump). The nurse knows that important considerations for this treatment include: SELECT ALL THAT APPLY

Correct Answer is ["A","B","D","E","F"]

Explanation

Heparin 7.,000 units is ordered. Heparin S.000 units per mL is available, How many milliliters (mL) should the nurse administer? ​​​​​​​(Do not round)

Correct Answer is ["1.4"]

Explanation

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An older client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory results are related to this finding, and should be reported to the health care provider immediately?