A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?

A medication is being administered IV through the injection site closest the client.

The blood has been infusing steadily for 5 hr with no client symptoms.

The packed RBCs are connected by Y tubing to normal saline.

The drip chamber with filter is filled completely with blood.

Answer and Explanation

The Correct Answer is C

A. Medications and blood should never be mixed in the same line because it can cause reactions, interference with the blood product, and complications for the client. Medications should be administered through a separate IV line or a port further away from the client.

B. Blood transfusions should typically be completed within 2 to 4 hours to reduce the risk of bacterial contamination and ensure that the blood does not exceed a safe infusion duration.

C. Y tubing is commonly used for blood transfusions, where one arm of the Y is used for the packed RBCs and the other is for normal saline. Normal saline is used to flush the line before and after administering blood, ensuring the infusion is free of air and that the blood flows smoothly without clotting.

D. The drip chamber should not be completely filled with blood. It should have a small amount of blood for monitoring the infusion rate, but the filter within the drip chamber is designed to filter any clots or debris. A completely filled chamber with blood can make it difficult to assess the flow rate, and could indicate that the blood is not flowing properly.

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Free Nursing Study Resources

Correct Answer is A

No explanation

A. "The Patient Self-Determination Act (PSDA) will explain your rights to change lifesaving measures." B. "The durable power of attorney for health care can cancel the client's living will." C. "The living will states the client's wishes regarding lifesaving measures." D. "The case manager can make changes to the client's living will."

Correct Answer is C

No explanation

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A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?

Nursing Test Bank

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