A nurse working at an assisted living facility is helping emergency medical services (EMS) triage clients after a fire in the building. The 83-year-old client suffered smoke inhalation. The client is coughing with a respiratory rate of 36 and reports shortness of breath. Using the START triage, what acuity level should be assigned to this client?

Choice A reason: Fidelity refers to the ethical principle of keeping promises and maintaining trust. In nursing, this principle involves being loyal to the client and upholding commitments made to them. While important, fidelity does not directly address the nurse's concern about the potential harm caused by administering the opioid medication.

Choice B reason: Nonmaleficence is the ethical principle of "do no harm." This principle is directly applicable in this scenario, as the nurse's concern is about potentially hastening the client's death by administering the opioid medication. By choosing not to administer the medication, the nurse is acting to avoid causing harm, aligning with the principle of nonmaleficence.

Choice C reason: Veracity is the principle of truthfulness and honesty. It involves providing accurate information to clients and being truthful in communication. Although important in healthcare, veracity does not specifically address the nurse's concern about the potential harm of administering the opioid medication.

Choice D reason: Utilitarianism is an ethical theory that focuses on the consequences of actions and aims to achieve the greatest good for the greatest number of people. While utilitarianism can guide decision-making in healthcare, it is not the most relevant principle in this scenario where the primary concern is avoiding harm to the individual client.

Choice A reason: This response acknowledges the friend's concern and respects Mary's privacy, but it implies that Mary is indeed having a difficult time, which is a breach of confidentiality. The nurse should not provide any information about the client's situation, even indirectly.

Choice B reason: This response directly shares information about Mary's condition, which is a violation of client confidentiality. The nurse must not disclose any details about a client's health status to someone who is not authorized to receive that information, regardless of their relationship with the client.

Choice C reason: This response is the most appropriate because it clearly states that the nurse cannot discuss any client situation. It respects client confidentiality and adheres to professional and legal standards of privacy.

Choice D reason: While this response directs the neighbor to ask Mary directly, it avoids the issue of confidentiality by not giving any information. However, it is less clear and professional compared to simply stating that the nurse cannot discuss client situations. The response should be straightforward and focused on upholding confidentiality.