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?

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

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.