A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.)
Initiating IV access on a client who has dementia while he is sleeping
Implementing a client's plan of care based upon nursing goals
Providing written information to a client regarding palliative care
Obtaining an interpreter for a client who speaks a different language than the nurse
Documenting a client's refusal to take a prescribed medication
Correct Answer : C,D,E
Rationale:
A. Initiating IV access while a client with dementia is sleeping violates autonomy and informed consent—this is not advocacy.
B. Implementing a plan of care based on nursing goals reflects nursing practice, but advocacy focuses on protecting the client’s rights and wishes, not just following nursing objectives.
C. Providing written information about palliative care supports informed decision-making, which is a key aspect of advocacy.
D. Obtaining an interpreter ensures the client understands their care and can make informed decisions, which is an advocacy action.
E. Documenting a client’s refusal of medication respects and upholds the client’s autonomy, which is a form of advocacy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client’s aPTT is within the therapeutic range for heparin, so immediate interdisciplinary discussion is not required.
B. Clients using insulin pumps require coordination between the nurse, endocrinologist, and diabetes educator to ensure safe insulin administration and blood glucose management, making an interdisciplinary conference appropriate.
C. Orthostatic hypotension being managed with IV fluids can typically be addressed within routine nursing care without needing an interdisciplinary meeting.
D. The client’s albumin level is within normal limits, and risk for pressure injuries can be managed with standard nursing interventions without requiring a conference.
Correct Answer is B
Explanation
Rationale:
A. Restarting an infiltrated IV is important for antibiotic therapy, but the dose is not due until 0900, so it is not the immediate priority.
B. Insulin aspart is a rapid-acting insulin that peaks quickly. The client must eat promptly to prevent hypoglycemia, making this the highest priority.
C. Administering pain medication for rheumatoid arthritis is necessary, but this is not life-threatening and can be addressed after preventing hypoglycemia.
D. Replacing an enteral feeding solution that has been hanging for 24 hr is important for infection control, but it is not as urgent as preventing acute hypoglycemia.
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