A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy?

"I will keep your personal information private."

"I will do my best to fulfill my promises to you."

"I will speak with your provider on your behalf."

"I will let you make decisions about your health care."

Answer and Explanation

The Correct Answer is D

Choice A reason: "I will keep your personal information private." is not a statement of advocacy, but a statement of confidentiality. Confidentiality is the ethical and legal obligation of the nurse to protect the client's privacy and information. Advocacy is the act of supporting and protecting the client's rights and interests.

Choice B reason: "I will do my best to fulfill my promises to you." is not a statement of advocacy, but a statement of accountability. Accountability is the responsibility of the nurse to answer for their actions and outcomes. Advocacy is the act of supporting and protecting the client's rights and interests.

Choice C reason: "I will speak with your provider on your behalf." is not a statement of advocacy, but a statement of communication. Communication is the exchange of information and ideas between the nurse and the client, the provider, and other members of the health care team. Advocacy is the act of supporting and protecting the client's rights and interests.

Choice D reason: "I will let you make decisions about your health care." is a statement of advocacy. Advocacy is the act of supporting and protecting the client's rights and interests, such as the right to informed consent, self-determination, and autonomy. The nurse should respect the client's choices and preferences, and assist them in making informed decisions.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect because the crutch tips should be about 15 cm (6 inches) away from the feet to provide stability and prevent tripping.

Choice B reason: This is correct because the three-point gait involves bearing weight on the unaffected leg while moving both crutches and the affected leg forward at the same time.

Choice C reason: This is incorrect because the crutches should be at the level of the hips, not the waist, to avoid pressure on the axillae and nerves.

Choice D reason: This is incorrect because the arms should be slightly bent at the elbows when walking to reduce fatigue and strain.

A. Using an oral care sponge swab moistened with cool water to clean the client's mouth. B. Wearing clean gloves to perform mouth care for the client. C. Lowering the side rail on the side of the bed where they will stand to perform mouth care. D. Using two gloved fingers to open the client's mouth for cleaning.

Correct Answer is D

Explanation

The correct answer is d. Using two gloved fingers to open the client’s mouth for cleaning. This action is unsafe as it risks injury to both the AP and the client. A padded tongue blade should be used instead.

Choice A reason:

Using an oral care sponge swab moistened with cool water to clean the client’s mouth is appropriate. Oral care sponge swabs are designed to clean the mouth gently and effectively, especially for unconscious patients.

Choice B reason:

Wearing clean gloves to perform mouth care for the client is a standard precaution to prevent infection. Gloves protect both the caregiver and the patient from potential infections.

Choice C reason:

Lowering the side rail on the side of the bed where they will stand to perform mouth care is necessary to safely access the patient. It allows the AP to perform the task without straining or risking injury.

Choice D reason:

Using two gloved fingers to open the client’s mouth for cleaning is unsafe. This method can cause injury to the AP if the patient bites down reflexively. A padded tongue blade should be used to safely open the mouth.

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A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

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