A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Choice A reason: Catheter placement for a nontunneled central venous access device is typically confirmed by X-ray, not a CT scan, to verify tip placement in the superior vena cava. CT scans are less common due to higher radiation and cost, making this statement inaccurate for standard practice.
Choice B reason: Elevating the head as high as possible during insertion is incorrect, as the Trendelenburg position (head down) is often used to distend veins and reduce air embolism risk. High head elevation could complicate insertion and increase complications, making this instruction inappropriate.
Choice C reason: Flushing the catheter with saline daily maintains patency, preventing clots and ensuring functionality of the nontunneled central venous access device. This is a standard care instruction, reducing infection and occlusion risks, and aligns with evidence-based protocols for central line maintenance, making it correct.
Choice D reason: Lying flat for 24 hours post-procedure is not required for nontunneled central venous catheters. Patients may need brief bed rest (e.g., 30 minutes) to prevent bleeding, but 24 hours is excessive and not evidence-based, making this instruction incorrect and overly restrictive.

Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.