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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Starting work in a parking garage while on warfarin does not inherently indicate a need for referral unless specific risks (e.g., injury prone to bleeding) are present. Without additional concerns, this situation is routine, making it incorrect for requiring further care.
Choice B reason: Increased urinary frequency with bumetanide, a diuretic, is an expected side effect, not requiring referral unless severe or accompanied by electrolyte imbalances. This is a normal response, so it does not warrant further care, making it incorrect.
Choice C reason: An induration 48 hours after a Mantoux test suggests a positive tuberculosis result, requiring referral for chest X-ray and further evaluation. This finding indicates potential latent or active TB, a significant health concern, making it the correct choice for referral.
Choice D reason: Being 1 day postoperative after knee replacement is expected, with routine monitoring for complications like infection or thrombosis. Without specific issues, this does not require referral beyond standard postoperative care, making it incorrect.

A. Refer the adolescent to a local mental health clinic. B. Contact the adolescent’s parent for assistance. C. Assist the adolescent in applying for Medicaid. D. Advise the adolescent to place the newborn for adoption.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following findings requires a referral for further care?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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