The nurse is caring for assigned clients. The nurse should first assess the client

A with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain). C with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic. B with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway. D one day postoperative from an open cholecystectomy with green drainage from the t-tube.