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

Explanation

The nurse should include that interpreting data is included in the step of:

A. Analysis:Interpreting data is a key part of the analysis step in critical thinking. This involves examining and making sense of the information collected, identifying patterns, and determining their relevance to the problem or decision at hand.

The other options do not specifically focus on interpreting data:

B. Intuition: Intuition involves understanding or knowing something without the need for conscious reasoning, which is more about gut feelings rather than analyzing data.

C. Creativity: Creativity involves generating new ideas or solutions, which is not directly related to interpreting existing data.

D. Questioning: Questioning involves asking questions to clarify information or challenge assumptions, but it is not the step where data interpretation occurs.

A. Ask an assistive personnel (AP) to verbalize the steps for removing an IV catheter. B. Research how to remove an IV catheter from the internet. C. Find an article in a nursing journal that is less than 5 years old on how to remove IV catheters. D. Review the facility's policies and procedures manual about removing IV catheters.

Correct Answer is D

Explanation

A.While an assistive personnel (AP) might assist with some tasks, they are not typically responsible for providing detailed procedural guidance on medical tasks. The nurse should seek guidance from established protocols and trained professionals.

B.While online resources can be helpful, they might not reflect the specific protocols or best practices of the facility. It's crucial to follow the facility’s policies and procedures to ensure consistency and compliance with organizational standards.

C.While reviewing current literature is beneficial for understanding best practices, the most immediate and relevant source of information is the facility's own policies and procedures. These documents will reflect the specific protocols that the facility requires.

D.Reviewing the facility's policies and procedures manual ensures that the nurse follows the specific guidelines and standards set by the institution. This approach aligns with organizational requirements and helps ensure that the procedure is performed correctly and safely within the context of the facility’s protocols.

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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

Naxlex Comprehensive Predictor Exams

A nurse is teaching a class about the steps of critical thinking. The nurse should include that interpreting data is included in which of the following steps?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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