After the nurse receives the change-of-shift report, which client should the nurse assess first?

Question

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The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client needs. This client with heart failure who is short of breath and coughing up pink frothy sputum has developed acute pulmonary edema (fluid filling the alveoli), a potentially life-threatening condition. This client's status has deteriorated from baseline, is potentially the most hemodynamically unstable, and should be assessed first. (Option A) This client with shortness of breath and high-pitched expiratory wheezing is experiencing expected clinical manifestations of asthma and is the second most unstable client at this time. (Option B) Diabetic stasis leg ulcers can be associated with large amounts of serous or serosanguineous drainage and is an expected manifestation. This client is not the most unstable at this time. (Option D) Absent breath sounds in the lung base in this client with pleural effusion is an expected finding as the collection of fluid in the pleural space prevents the lung from expanding. This client is not the most unstable at this time. Educational objective: Information communicated in the change of shift report should provide the nurse with information needed to identify the type of problem the client has, its associated complications, and the risks to survival. The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client needs.

After the Nurse Receives the Change-Of-Shift Report, Which Client Should