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: Ritualistic behavior is linked to obsessive-compulsive personality disorder, not narcissistic personality disorder (NPD). NPD involves self-focused grandiosity, not repetitive rituals driven by anxiety. These distinct psychological mechanisms make ritualistic behavior an unlikely finding in clients with NPD during assessment.
Choice B reason: Suspiciousness is characteristic of paranoid personality disorder, not NPD. While NPD clients may distrust due to ego threats, this is secondary to their grandiose self-view. Suspicion is not a core NPD trait, as their focus is on admiration, not pervasive mistrust.
Choice C reason: Preoccupation with aging is not a primary NPD feature. NPD clients focus on idealized self-image, but aging fears are more tied to body dysmorphic disorder or general anxiety. This preoccupation is not a diagnostic criterion for NPD in psychological assessments.
Choice D reason: A grandiose sense of self is a core NPD feature, marked by exaggerated self-importance and entitlement. Driven by fragile self-esteem, this trait leads to behaviors like boasting, as defined in DSM-5 criteria, making it an expected finding during assessment of NPD clients.
Correct Answer is C
Explanation
Choice A reason: Referring to a mental health clinic addresses potential emotional distress but not the adolescent’s primary concern of affordability. Pregnancy increases psychological stress, but financial barriers to prenatal care are critical. This action fails to ensure access to medical resources, essential for maternal and fetal health in adolescent pregnancy.
Choice B reason: Contacting the adolescent’s parent risks breaching confidentiality, depending on legal guidelines, and does not address financial concerns directly. Family dynamics may complicate support, and without consent, this action could increase stress, failing to provide immediate healthcare access critical for a healthy pregnancy outcome.
Choice C reason: Assisting with Medicaid application directly addresses financial concerns, ensuring access to prenatal care, delivery, and postpartum support. Medicaid reduces risks like preterm birth by covering medical and nutritional needs, critical for adolescent mothers with limited resources, aligning with public health goals for maternal-fetal well-being.
Choice D reason: Advising adoption is premature and overlooks the adolescent’s autonomy. Adoption requires extensive counseling, not immediate recommendation. It fails to address healthcare access, critical for a healthy pregnancy. This approach dismisses financial solutions, potentially increasing stress and undermining informed decision-making in pregnancy.
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