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

Choice A rationale Pitting edema of 1+ is a common manifestation of congestive heart failure due to increased hydrostatic pressure within the venous system. While it indicates fluid volume overload, it is typically a chronic finding and does not represent an immediate threat to the airway, breathing, or circulation. The nurse should monitor this finding during the shift, but it lacks the urgency required for a first assessment compared to acute cardiac changes in other patients. Choice B rationale An audible S3 heart sound in an adult who has suffered a myocardial infarction is a significant clinical finding. This ventricular gallop occurs during early diastole and often indicates the onset of heart failure or ventricular dysfunction. It suggests that the left ventricle is failing to pump effectively, leading to increased pressure. Given the high risk of rapid deterioration and cardiogenic shock after an infarct, this patient is the priority for immediate assessment and intervention. Choice C rationale Chronic renal failure is characterized by a persistent decrease in glomerular filtration rate, which naturally results in an elevated serum creatinine level. The normal creatinine range is approximately 0.6 to 1.2 mg/dL. In a client with known chronic disease, a high level is an expected baseline finding rather than an acute change. Unless the level is extremely high or accompanied by symptoms of uremic toxicity, this patient does not require the first assessment. Choice D rationale A pulse oximetry reading of 94 percent in a patient with pneumonia is generally considered acceptable and within a stable range. Most clinical protocols target an oxygen saturation of 92 percent or higher for patients with lung infections. While the nurse should continue to monitor respiratory effort and breath sounds, this saturation level indicates adequate gas exchange. It does not take precedence over a potential acute cardiac failure indicated by a new heart sound.