A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.
While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Choice A rationale

While the client’s healthcare power of attorney is important information, it is not the most critical piece of information to report in this situation. The immediate concern is the client’s change in mental status and potential medical emergency.

Choice B rationale

The nurse should be aware of the client’s currently prescribed medications, but this information does not take precedence over the client’s sudden onset of confusion and agitation. Immediate action is needed to address the client’s altered mental status.

Choice C rationale

While the reason for the client’s admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client’s acute change in mental status.

Choice D rationale

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client’s immediate needs.

The correct answer is D. The practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients is best assigned to an adult who is one day postoperative for a laparoscopic cholecystectomy. This client’s care involves routine postoperative care and monitoring, which is within the PN’s scope of practice. The other clients have more complex needs that require the higher level of education and skills of an RN.