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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?

A.

"This helps to keep you hydrated."

B.

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

C.

"This makes sure it stays sterile."

D.

"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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Related Questions

Correct Answer is D

Explanation

Rationale:

A. Use a mechanical voice amplifier: A voice amplifier benefits clients with impaired vocal strength but does not help clients with expressive aphasia, who struggle to form or express language, not to project it audibly.

B. Provide educational materials with large print: Large print materials are helpful for clients with visual impairments but do not address language expression difficulties. Expressive aphasia requires alternative communication strategies, not visual aids.

C. Have the client's glasses brought from home: Glasses improve vision, not speech or language production. While helpful overall, they do not assist with the core issue of expressive aphasia, which is rooted in brain-language pathways.

D. Establish alternatives to verbal conversation: Using picture boards, writing tools, gestures, or communication apps helps clients express needs and ideas despite speech limitations. These strategies support more effective communication in expressive aphasia.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Rationale:

  • Prolonged rupture of membranes: Membranes ruptured for over 24 hours (28 hr), increasing the risk for ascending bacterial infections such as endometritis or chorioamnionitis.
  • Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
  • Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
  • High parity: Repeated stretching of the uterus in grand multiparity reduces muscle tone, making the uterus less responsive to postpartum contraction and more prone to atony.

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