A nurse is flushing a client's intermittent infusion device. The client states, "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make?

"This helps to keep you hydrated."

"This clears blood from the tubing and the catheter."

"This makes sure it stays sterile."

"This prevents leakage of fluid and medication."

Answer and Explanation

The Correct Answer is B

Rationale:

A. "This helps to keep you hydrated.": Flushing an intermittent infusion device does not hydrate the client, as the small amount of saline used is not intended for fluid replacement. Hydration is achieved through continuous or scheduled fluid administration, not flushes.

B. "This clears blood from the tubing and the catheter.": Flushing helps maintain catheter patency by preventing blood from clotting inside the lumen. It ensures the device remains functional and ready for medication administration when needed.

C. "This makes sure it stays sterile.": Flushing does not sterilize the device. Sterility is maintained through proper handling and use of aseptic technique. The purpose of flushing is mechanical, not antimicrobial.

D. "This prevents leakage of fluid and medication.": While flushing may help confirm that the device is intact, the primary reason is not to prevent leakage but to maintain patency and ensure the catheter is free of occlusions.

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Correct Answer is D

Explanation

Rationale:

A. Decreased creatine kinase-MB: CK-MB is a cardiac enzyme that rises within 4–6 hours of myocardial infarction and peaks around 24 hours. A decrease in CK-MB would not indicate acute myocardial injury and is not a diagnostic marker in this case.

B. Decrease in respiratory rate: A lower respiratory rate is not a typical or reliable indicator of myocardial infarction. Clients experiencing an MI are more likely to show signs of dyspnea, anxiety, or increased respiratory effort due to pain or decreased oxygenation.

C. ST segment depression: ST segment depression may indicate myocardial ischemia or a non-ST elevation myocardial infarction (NSTEMI), but it is less specific than biomarkers like troponin. It may also appear in other conditions such as angina or electrolyte imbalances.

D. Increased troponin I: Troponin I is a highly specific and sensitive cardiac biomarker that rises within 3–6 hours of myocardial injury. An elevated troponin I level 6 hours after the onset of chest pain strongly supports the diagnosis of myocardial infarction.

A. "Decrease your intake of cranberry juice." B. "Limit your fluid intake to 500 milliliters per day." C. "Plan to urinate every 3 hours while you are awake." D. "Take your diuretic medication with your evening meal."

Correct Answer is C

Explanation

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

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A nurse is flushing a client's intermittent infusion device. The client states, "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make?

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