Exhibits

The practical nurse (PN) calls the healthcare provider to notify them that the heart rate is too low to administer the digoxin.

Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have at only one answer selected.

A. Assist the client to perform active range of motion and back exercises: Active exercises can be beneficial in rehabilitation phases but may worsen pain if done too early or without proper pain control. Immediate strategies should focus on comfort and supporting medication effectiveness before promoting activity.
B. Force fluids and progress diet to include milk products: While hydration and nutrition are important for overall health, they do not directly enhance the immediate effectiveness of analgesics. This intervention is unrelated to managing or reducing the client's current low back pain.
C. Reposition the client with proper alignment and massage the lower back: Proper repositioning reduces strain on the spine, improves comfort, and enhances the action of analgesics. Gentle massage promotes circulation and relaxation, helping to amplify pain relief when combined with medication.
D. Encourage the client to take deep breaths and to ambulate frequently: Deep breathing and early ambulation are excellent for preventing complications like pneumonia and deep vein thrombosis especially in clients with decreased mobility due to pain but may not be appropriate as an initial intervention to maximize immediate pain relief from analgesics.

A. Sacrum: The sacrum is a common site for pressure ulcers in a supine position, but once the client is turned onto the side, pressure shifts away from the sacrum to lateral body surfaces. It is not the most at-risk area in the new position.
B. Ischial tuberosities: The ischial tuberosities bear weight when sitting, not typically when lying in a lateral position. Therefore, they are less likely to be the first site to show erythema when turned onto the side.
C. Lateral malleolus: The lateral malleolus can be at risk when the lower legs rub against the bed, but it is a smaller surface area and would show signs later compared to larger, more pressure-exposed areas like the iliac crest.
D. Iliac crest: The iliac crest on the side the client is turned onto bears significant pressure in the lateral position. It is a major bony prominence directly exposed to force against the mattress, making it the most likely site to show early erythema.