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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Disconnecting the catheter from the drainage bag to empty the bag: This increases the risk of introducing pathogens into the closed urinary drainage system, leading to potential catheter-associated urinary tract infections (CAUTIs). The drainage bag should be emptied without breaking the system.
B. Emptying the drainage bag when it is half full: This prevents backflow of urine, which could lead to infection or increased bladder pressure. Regular emptying also allows for accurate measurement of urine output and maintains client comfort.
C. Keeping the drainage bag above waist level: Elevating the bag above the bladder increases the risk of backflow of urine into the bladder, which can introduce bacteria and cause infection. The bag should always remain below the level of the bladder.
D. Using sterile gloves when emptying the drainage bag: Sterile gloves are not necessary for this procedure. Clean gloves are sufficient since the nurse or AP is not entering the sterile parts of the urinary system but rather emptying the bag from the outlet port.
Correct Answer is C
Explanation
Rationale:
A. Providing the client with information about transportation services: This helps address access barriers but focuses on support services rather than directly organizing or integrating healthcare delivery, which is central to coordination of care.
B. Informing the client about providers who accept their health insurance: While helpful, this action centers on financial guidance. It supports access but does not actively bridge or organize care among multiple services or settings.
C. Arranging an appointment for the client with a mobile health clinic: Coordinating an appointment directly connects the client with needed services, especially in underserved rural areas. This reflects active care coordination by ensuring timely access to care and reducing system fragmentation.
D. Encouraging the client to become a self-advocate: Promoting self-advocacy empowers the client in their health journey but does not represent coordination of care. Coordination involves organizing and facilitating access across providers and settings.
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