A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores.
The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.

This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.

The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.

Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.

Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.

It has no effect on the oxygen saturation level.

Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.

A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.

Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.

The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.

The correct answer is choice A. Evaluate the client’s concerns and communicate them to the provider.

This is because the nurse’s role as a patient advocate is to speak, act or behave in a way that benefits their patient, who may not be able to support or promote their own needs or interests.

The nurse should provide patients with information regarding their diagnoses, prognoses, treatments, and alternatives, and serve as a patient’s voice when necessary.

Choice B is wrong because contacting the unit’s social worker to report the client’s refusal is not an appropriate action for the nurse to take as a patient advocate.

The nurse should respect the patient’s autonomy and right to refuse treatment, and not involve other professionals without the patient’s consent.

Choice C is wrong because asking the client’s partner to find out why the client has refused the procedure is not an appropriate action for the nurse to take as a patient advocate.

The nurse should communicate directly with the patient and not rely on third parties to obtain information or influence the patient’s decision.

Choice D is wrong because explaining the necessity of the procedure to the client is not an appropriate action for the nurse to take as a patient advocate.

The nurse should not impose their own values or opinions on the patient, but rather provide unbiased and factual information and support the patient’s informed choice.