The nurse is notifying the HCP of the client's change in status using the SBAR format. In which order should the nurse place the statements?

1. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client."

2. "The client is deteriorating, and I'm afraid the client is going to arrest."

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)."

4. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask."

A. A nurse gives a client the choice to take a pain medication via intramuscular or oral route: This action exemplifies the ethical principle of autonomy, as it respects the client’s right to make decisions regarding their own treatment options.

B. A nurse administers scheduled pain medication for a client who is having pain: This action reflects the principle of beneficence, which emphasizes the obligation to act in the best interest of the client and alleviate suffering. Administering pain medication according to the schedule supports the client's well-being.

C. A nurse fulfills a promise to a client that they will return with their pain medication: This action demonstrates fidelity, which involves keeping promises and commitments made to clients. It ensures trust and accountability in the nurse-client relationship.

D. A nurse provides nonpharmacological pain interventions to each client equally: This action represents the principle of justice, which emphasizes fairness and equality in the distribution of resources and treatment among clients. Providing equal access to pain interventions ensures that all clients receive appropriate care regardless of their individual circumstances, aligning with the ethical principle of justice.

A. Preventing the client from sliding in bed: This activity directly addresses shearing forces, which occur when the skin is pulled in one direction while the underlying tissues move in another. By preventing the client from sliding down in bed, the nurse can reduce the risk of shearing, thereby helping to protect the integrity of the skin and the existing pressure injury.

B. Lubricating the area with skin cream: While applying skin cream can help keep the skin hydrated and may assist in overall skin health, it does not directly prevent shearing forces. Lubrication is more about skin protection and moisture retention rather than reducing mechanical forces acting on the skin.

C. Improving the client's hydration: While maintaining good hydration is important for skin health and can aid in the healing process, it does not specifically address the mechanical forces that cause shearing. Proper hydration helps maintain skin elasticity but does not prevent movement-related injuries.

D. Pulling the client up from under the arms: This method can actually increase the risk of shearing forces and potential injury to the client. Instead, using a draw sheet or a transfer device to reposition the client helps to reduce friction and shearing when moving the client up in bed. Proper techniques should always be employed to minimize the risk of skin damage.