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 D
Explanation
Choice A reason: Assuring the client about future pregnancies dismisses her current emotional loss, potentially invalidating grief. Stillbirth triggers complex hormonal and psychological responses, including postpartum depression risk. This approach fails to address immediate emotional needs, hindering the grieving process and emotional recovery in perinatal loss.
Choice B reason: Avoiding discussion of the newborn ignores the client’s need to process her loss. Acknowledging the baby’s existence is critical for healthy mourning, as psychological research shows verbalizing grief aids emotional integration. Silence may suppress coping, prolonging unresolved grief and complicating psychological adjustment post-stillbirth.
Choice C reason: Discouraging friends from seeing the newborn dismisses the client’s need for social support. Communal acknowledgment of loss mitigates isolation, a key factor in grief recovery. This action disrupts psychological coping by limiting social validation, potentially exacerbating feelings of loneliness and hindering emotional healing after stillbirth.
Choice D reason: Offering to take pictures acknowledges the baby’s significance, aiding the client’s grieving process. Photographs serve as tangible memories, supported by psychological research as therapeutic in perinatal loss. This intervention fosters emotional closure, validates the loss, and supports healthy mourning, aligning with compassionate care principles.
Correct Answer is B
Explanation
Choice A reason: Washing hands for 10 seconds with hot water is insufficient; at least 20 seconds with soap and warm water is recommended to remove pathogens post-gardening. Hot water alone is ineffective, so this statement reflects incomplete understanding, making it incorrect.
Choice B reason: Visiting a nephew with chickenpox 5 days after sores crust indicates understanding, as the virus is no longer contagious then. This aligns with CDC guidelines for varicella, protecting the pregnant client and fetus, making it the correct statement.
Choice C reason: Cleaning a cat’s litter box during pregnancy risks toxoplasmosis, which can harm the fetus. Pregnant women should avoid this task, so this statement shows a lack of understanding, making it incorrect for infection prevention.
Choice D reason: Avoiding anyone with a cold sore is overly restrictive, as herpes simplex transmission requires direct contact. General avoidance without context reflects misunderstanding, as precautions like avoiding kissing suffice, making this incorrect.
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