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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Correct Answer is D

Explanation

A. Decreased urine specific gravity:In fluid volume deficit, urine becomes more concentrated due to decreased kidney perfusion and water conservation by the body. This results in an increased urine specific gravity.

B. Decreased Hgb:Fluid volume deficit typically leads to hemoconcentration because there is less plasma volume, which makes hemoglobin and hematocrit levels appear elevated.

C. Increased urine ketones:While increased urine ketones may occur in dehydration associated with starvation or diabetic ketoacidosis (DKA), it is not a hallmark finding in general fluid volume deficit. The presence of ketones depends on the underlying cause, not on fluid volume status alone.

D. Increased BUN:Blood urea nitrogen (BUN) increases in fluid volume deficit because of hemoconcentration and reduced kidney perfusion, which slows the excretion of urea. The ratio of BUN to creatinine is often elevated in dehydration (>20:1).

A. Nausea and vomiting B. Flushed skin C. Extreme thirst D. Fever

Correct Answer is A

Explanation

A.Severe hyponatremia can cause nausea and vomiting due to the disturbance in electrolyte balance and the effects on the central nervous system. It is a common symptom associated with low sodium levels.

B.Flushed skin is not typically associated with hyponatremia. This is more commonly seen in conditions such as fever, inflammation, or allergic reactions.

C.Extreme thirst is more associated with hypernatremia (high sodium levels) rather than hyponatremia. In hyponatremia, the client might have a reduced sensation of thirst or might experience symptoms related to fluid overload.

D. Fever is not a direct symptom of hyponatremia. It can be associated with infections or inflammatory conditions, but it is not a typical manifestation of low sodium levels.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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