Difficulty: Medium
Average Score: 64%
Simulated
The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?
Correct answer
A
Rationale
An S3 heart sound post-MI (A) indicates heart failure or fluid overload, requiring immediate assessment. Edema (B) is chronic, 94% SpO2 (C) is stable, and elevated creatinine (D) is expected in CRF.