A nurse in a long-term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first?

A. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most clients and does not indicate respiratory compromise. No immediate provider notification is necessary based solely on this oxygen saturation level during opioid therapy.

B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is normal. Significant respiratory depression from opioids like hydromorphone would typically be indicated by a rate lower than 12 breaths per minute.

C. Urinary output 160 mL/8 hr: Urinary output should be at least 30 mL/hr. A total of 160 mL in 8 hours is significantly low, suggesting possible urinary retention or decreased renal perfusion, both of which can be side effects of opioid use and should be reported promptly.

D. Blood pressure 108/58 mm Hg: While this blood pressure is on the lower side, it is not critically low for many adults. Unless the client is symptomatic with dizziness or fainting, this blood pressure alone does not require immediate provider notification.

• Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
• Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
• Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
• Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
• Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
• Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.