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. Remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown: Frequent repositioning is critical to prevent pressure injuries in bedfast clients. Although the redness blanched (indicating no permanent damage yet), regular turning is necessary to maintain skin integrity and prevent future breakdown.
B. Confirm that turning this client once a shift is sufficient since no skin damage occurred: Turning once per shift is inadequate for pressure injury prevention. Clients at risk need to be repositioned at least every two hours to minimize sustained pressure on bony prominences.
C. Instruct the UAP to cleanse the area thoroughly to remove any remaining skin debris: Since there is no open wound, aggressive cleansing is unnecessary and could actually irritate the skin further. The focus should be on pressure relief rather than harsh skin cleansing.
D. Gather supplies to apply a sterile dressing over the site to reduce risk for infection: A sterile dressing is not appropriate for blanchable redness without skin breakdown. Preventive measures like repositioning and pressure relief are the correct interventions at this stage.

A. Acknowledge the client's concerns and notify the healthcare provider of the client's wishes: While it is important to acknowledge the client's feelings, immediately notifying the healthcare provider is not the first or most critical action. The client first needs a clear explanation of the purpose of the advance directive.
B. Ask a family member to describe the client's stated wishes regarding end-of-life care: Involving family members at this stage may undermine the client's autonomy. The focus should be on informing and empowering the client to make his own decisions.
C. Explain that the form identifies his personal health care wishes for any future event: It is important to clarify that advance directives are not just for those who are dying but help ensure that healthcare decisions align with the client’s wishes if he becomes unable to communicate in the future. Clear communication can ease misunderstandings and support informed decision-making.
D. Document his refusal in his electronic medical record using his exact words: While documentation is important, it should occur after ensuring that the client fully understands the purpose of the form. Providing education first supports client rights and informed consent.