After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first?
a. A patient who is cool and clammy, with new-onset confusion and restlessness
b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen.
c. A patient who had dizziness after receiving the first dose of captopril (Capoten)
d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
ANS: A
The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.
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