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 prevents leakage of fluid and medication.
This helps to keep you hydrated.
This clears blood from the line.
This ensures the device is sterile.
The Correct Answer is C
Choice A reason: Preventing leakage is not the primary purpose of flushing an intermittent infusion device. Flushing maintains patency by clearing blood or medication residue, preventing clots or blockages. Leakage is addressed by proper capping or clamping, not flushing, making this statement incorrect as it misrepresents the procedure’s purpose.
Choice B reason: Flushing an infusion device does not contribute to hydration, as the flush solution (typically saline) is minimal and not intended for fluid replacement. The purpose is to maintain catheter patency by clearing debris or clots. This statement is incorrect, as it inaccurately suggests a hydration benefit unrelated to the procedure.
Choice C reason: Flushing an intermittent infusion device with saline clears blood or medication residue from the catheter, preventing occlusion and maintaining patency. Blood left in the line can clot, increasing infection risk or blocking the device. This statement accurately reflects the procedure’s purpose, ensuring continued functionality for future medication administration.
Choice D reason: Flushing does not ensure sterility, as the device is already in place and exposed to the bloodstream. Sterility is maintained during insertion or access, not flushing. The primary goal is patency, not sterilization, making this statement incorrect as it misaligns with the procedure’s clinical purpose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Taking diuretics with the evening meal increases nighttime urination, worsening urge incontinence by stimulating bladder activity during sleep. Diuretics should be taken earlier (e.g., morning) to align with daytime voiding schedules, reducing urgency episodes. This instruction is counterproductive for bladder retraining, making it inappropriate.
Choice B reason: Planning to urinate every 3 hours while awake establishes a scheduled voiding regimen, a key component of bladder retraining. This helps condition the bladder to delay urgency, reducing involuntary contractions and improving control. It aligns with evidence-based strategies for managing urge incontinence, making it the correct instruction.
Choice C reason: Limiting fluid intake to 1 liter per day risks dehydration and concentrated urine, which can irritate the bladder and worsen urge incontinence. Adequate hydration (2-3 L/day) supports bladder health and retraining by maintaining normal urine volume, making this instruction harmful and incorrect.
Choice D reason: Performing Kegel exercises once daily is insufficient for effective bladder retraining. Multiple daily sets (e.g., 3-4 times) strengthen pelvic floor muscles, improving bladder control. This frequency is too low to achieve therapeutic benefits for urge incontinence, making it less effective than scheduled voiding.
Correct Answer is B
Explanation
Choice A reason: Financial power of attorney manages monetary decisions, not health care, unless specified as a health care surrogate. Advance directives guide health decisions, but this role is distinct, making this statement incorrect under the Patient Self-Determination Act’s provisions.
Choice B reason: The Patient Self-Determination Act ensures clients’ rights to refuse treatment, even against provider recommendations, promoting autonomy through advance directives. This legal protection applies in Medicare/Medicaid facilities, making it the correct principle for end-of-life decision-making in this context.
Choice C reason: Advance directives can be changed by a competent client, even if notarized, as the Act supports ongoing autonomy. Stating they cannot be altered is incorrect, as flexibility is a core feature, making this an inaccurate representation of the law.
Choice D reason: The eldest adult child cannot change advance directives unless designated as a surrogate. The Act prioritizes the client’s documented wishes or appointed decision-maker, not family hierarchy, making this statement incorrect and misaligned with legal requirements.
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