The nurse is in the room of a client who had a lengthy surgery yesterday. As the nurse speaks with the client, the client suddenly starts to cough, reports difficulty breathing, and is anxious. The nurse places the client in semi-Fowler's position and obtains vital signs. What additional assessment is a priority?

Postoperative clients are at increased risk for acute respiratory complications such as pulmonary embolism, atelectasis, or aspiration due to immobility, anesthesia effects, and impaired ventilation. Sudden onset of cough, dyspnea, and anxiety is an urgent clinical presentation that requires immediate evaluation of oxygenation and respiratory status. Rapid assessment focuses on identifying life-threatening hypoxemia and ventilation compromise. Prioritizing respiratory function is essential in preventing rapid deterioration. Rationale: A. Auscultation of the apical heart rate and rhythm is important for cardiac assessment but is not the priority in a client with acute respiratory distress. Cardiac complications may contribute to symptoms, but the immediate concern is impaired oxygenation and ventilation. Respiratory assessment must be completed first to identify potentially life-threatening hypoxia. B. Measuring oxygen saturation and auscultating lung fields is the priority assessment because it directly evaluates the client’s oxygenation and ventilation status. Sudden dyspnea and cough may indicate pulmonary embolism, atelectasis, or other acute pulmonary complications. Low oxygen saturation and abnormal breath sounds such as crackles or absent breath sounds can help rapidly identify the cause of deterioration. C. Assessing the surgical site for bleeding and infection is important in postoperative care but is not the immediate priority given the acute respiratory symptoms. The client’s presentation suggests a possible pulmonary complication rather than a surgical site issue. Airway and breathing assessment must take precedence over wound evaluation. D. Evaluating respiratory secretions and cough frequency provides supportive information but does not address the immediate risk of hypoxemia. Although secretion buildup may contribute to coughing, it does not explain sudden severe dyspnea as urgently as oxygenation status. Priority remains identifying impaired gas exchange through oxygen saturation and lung auscultation.