After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first?

Question

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The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for a pulmonary embolism (PE). Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. (Option B) This client likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE. Pneumonia is fatal to clients within a period of days (rarely hours), but PE can lead to death in minutes to hours, depending on its severity. (Option C) This client requires a thorough respiratory assessment. However, this client arrived 15 minutes ago, vital signs, including pulse oximetry, were already measured; and the day shift nurse who received the report from the PACU nurse assessed the client. (Option D) Flank pain is expected in a client who is hospitalized for a kidney stone. Providing pain relief and comfort are priorities, but this client does not have the most urgent problem. Educational objective: The hand-off nurse-to-nurse report provides the oncoming nurse with necessary information about the clients' immediate needs, problems, and potential complications. The nurse can then use different frameworks, such as airway, breathing, circulation, Maslow's Hierarchy of Needs, degree of threat to survival, and the potential for complications to help decide which clients need immediate attention and which ones can wait.

After Receiving the Hand-Off Nurse-To-Nurse Evening Shift Report, Which Client