Question

The nurse on the telemetry unit has just received AM shift report. Which client should the nurse assess first?

a. The client diagnosed with MI who has an audible S3 heart sound,
b. The client diagnosed with CHF who has 4+ sacral pitting edema.
c. The client diagnosed with pneumonia who has a pulse ox reading of 94%.
d. The client with chronic renal failure who has an elevated creatinine levels.

Answer 1

The nurse should prioritize assessing the client with a myocardial infarction (MI) exhibiting an S3 heart sound as it can indicate imminent heart failure, which is a critical and potentially life-threatening condition.

Step-by-step explanation:

The priority for the nurse in the telemetry unit would be to assess the client who has the most critical and potentially life-threatening condition first. An S3 heart sound in a client with a myocardial infarction (MI) can indicate heart failure, which requires immediate attention. While a client with chronic heart failure (CHF) and severe sacral pitting edema or a client with chronic renal failure and elevated creatinine levels also present significant concerns, these conditions typically do not progress as rapidly as complications of an MI. A patient with pneumonia and a pulse ox reading of 94% is generally considered stable, as normal pulse oximetry readings range from 95% to 100%; however, this could indicate the onset of respiratory problems and should not be ignored, but it is not as urgent as the potential heart failure in the MI patient.