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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is true. Fluid volume deficit, or hypovolemia, is a condition where the body loses more fluid than it gains. It can be caused by fluid loss from vomiting, diarrhea, bleeding, or excessive sweating. Fluid volume deficit can lead to dehydration, hypotension, tachycardia, and shock.
Choice B reason: This statement is false. Sodium imbalance, or dysnatremia, is a condition where the blood sodium level is either too high or too low. It can be caused by fluid imbalance, kidney disease, hormonal disorders, or medications. Sodium imbalance can affect the brain function, causing confusion, seizures, or coma.
Choice C reason: This statement is false. Potassium imbalance, or dyskalemia, is a condition where the blood potassium level is either too high or too low. It can be caused by kidney disease, acid-base disorders, medications, or dietary intake. Potassium imbalance can affect the heart function, causing arrhythmias, cardiac arrest, or death.
Choice D reason: This statement is false. Fluid volume excess, or hypervolemia, is a condition where the body gains more fluid than it loses. It can be caused by fluid overload, heart failure, kidney failure, or liver disease. Fluid volume excess can lead to edema, hypertension, dyspnea, and pulmonary congestion.
Correct Answer is B
Explanation
Choice A reason: This statement is false. Drinking more fluids in the late evening can cause nocturia, which is the need to urinate frequently at night. This can disrupt the sleep cycle and increase the risk of falls.
Choice B reason: This statement is true. Dry mouth is a sign of dehydration and indicates the need for more fluid intake. Older adults may have reduced thirst sensation and may not drink enough fluids throughout the day.
Choice C reason: This statement is false. Caffeine is a diuretic, which means it increases urine output and can worsen dehydration. Confusion is a symptom of dehydration and requires immediate medical attention.
Choice D reason: This statement is false. Feeling full is not a reliable indicator of hydration status. Older adults may have decreased appetite and gastric motility, which can make them feel full even when they are dehydrated.
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