Which of the following statements by a client with human immunodeficiency virus (HIV) requires further teaching or clarification? (Select all that apply.)

Choice A reason: Calling a chaplain is not the priority nursing action for a client who is in critical condition and hypotensive. The chaplain may not be available or may not be able to provide adequate support to the spouse. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.

Choice B reason: Maintaining the client’s blood pressure is the priority nursing action for a client who is in critical condition and hypotensive. The nurse should monitor the client’s vital signs, administer fluids and medications, and provide oxygen as ordered. This choice addresses the client’s urgent medical needs and may prevent further complications.

Choice C reason: Providing the spouse a chair is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not want to sit down or may not be able to stay calm. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.

Choice D reason: Asking the client’s spouse to explain what happened is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not be able to recall or communicate the details of the event. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.

Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.

Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.

Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.

Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.

Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.