A nurse is observing an assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene?

Rationale:
A. Initiating access while a client with dementia is sleeping is not an example of advocacy. It violates the client’s autonomy and may be unsafe or unethical. Client advocacy requires respecting the client’s rights and ensuring informed, voluntary participation.

B. Implementing a plan of care based on nursing goals does not necessarily represent advocacy unless it aligns with the client’s preferences and needs. Advocacy focuses on the client’s interests, not solely the nurse’s goals.

C. Obtaining an interpreter is an example of advocacy because it ensures the client can understand and participate in healthcare decisions, promoting autonomy and informed consent.

D. Documenting a client’s refusal of medication is a form of advocacy because it respects the client’s right to make decisions about their care and ensures their preferences are communicated to the healthcare team.

E. Providing written information about palliative care is advocacy because it empowers the client to make informed choices regarding end-of-life care, supporting autonomy and informed decision-making.

Rationale:
A. Asking the client’s family to contact the insurance provider may delay timely resolution. While insurance approval may be necessary, coordinating delivery is the responsibility of the healthcare team to ensure client safety.

B. Contacting social services may help with long-term arrangements, but it is not the immediate priority when the client requires oxygen for safe discharge. Social services can assist in arranging resources, but the provider must first be informed.

C. Notifying the provider about the delayed oxygen tank delivery is the appropriate action. The provider needs to be aware because the client cannot be safely discharged without the prescribed oxygen, and alternative arrangements, such as delaying discharge or providing temporary in-hospital oxygen, may be required. This ensures client safety and adherence to discharge orders.

D. Sending an oxygen tank from the facility home with the client is not allowed. Hospital oxygen tanks are for facility use and are regulated; transferring them offsite is unsafe and typically prohibited by policy and law.