When an older client with heart failure is transferred to the medical service, what should the nurse do first?

Prioritizing the assessment of a client’s heart and lung sounds is crucial when dealing with an older adult who has heart failure. This condition often leads to congestion in the lungs and heart-related issues. By assessing heart sounds, the nurse can evaluate the functionality of the heart, including checking for irregular rhythms, murmurs, or signs of heart failure progression, such as gallops.

Similarly, lung sounds can provide vital information regarding fluid buildup, which is a common issue in heart failure patients. The presence of crackles or wheezing can indicate pulmonary edema or other complications, requiring immediate intervention.

Performing this assessment helps to form a baseline understanding of the client’s current status and guides further interventions, making it the foundational step in managing the client’s care effectively. Other actions, such as interviews or monitoring vital signs, while important, follow this initial assessment to ensure any immediate complications are addressed promptly.