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: Using a narrower cuff to repeat the BP measurement is an incorrect action by the nurse, as it can result in a falsely high reading. The nurse should use a cuff that fits the client's arm size and circumference.

Choice B reason: Measuring the client's BP in the other arm is the correct action by the nurse, as it can help to confirm the accuracy of the reading and rule out any possible errors or variations. The nurse should compare the readings from both arms and report any significant differences to the provider.

Choice C reason: Deflating the cuff faster when repeating the BP measurement is an incorrect action by the nurse, as it can result in a falsely low reading. The nurse should deflate the cuff at a rate of 2 to 3 mm Hg per second.

Choice D reason: Requesting a prescription for an antihypertensive medication is an inappropriate action by the nurse, as it is premature and unnecessary. The nurse should first verify the BP reading and identify the possible causes of the elevation, such as pain, anxiety, or medication effects. The nurse should also implement nonpharmacological interventions, such as positioning, relaxation, and oxygen therapy, before administering any medication.

A. Clean around the urinary meatus from front to back. B. Separate the labia with the nondominant hand. C. Insert the catheter into the urethral meatus. D. Secure the catheter to the client's thigh. E. Inflate the catheter balloon.

Correct Answer is A,B,C,E,D

Explanation

Choice 1 reason: This is the first step because cleaning the urinary meatus reduces the risk of infection and contamination.

Choice 2 reason: This is the second step because separating the labia exposes the urethral meatus and facilitates the insertion of the catheter.

Choice 3 reason: This is the third step because inserting the catheter into the urethral meatus allows the urine to drain into the collection bag.

Choice 4 reason: This is the fourth step because inflating the catheter balloon secures the catheter in place and prevents it from slipping out.

Choice 5 reason: This is the fifth step because securing the catheter to the client's thigh prevents tension and traction on the catheter and the bladder.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 125/85 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,E,D

Explanation

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