The nurse plans to collect data on a client who has been admitted with mild respiratory distress secondary to pulmonary edema. When planning the sequence of the assessment, the nurse would do which of the following?
1. Plan to assess the client to minimize position changes.
2. Perform the respiratory assessment first.
3. Assess from head-to-toe.
4. Begin by assessing cardiac status.
2
Rationale: The priority for assessment is the respiratory system because this is the source of the client's distress. Minimizing position changes would not be a consideration, because movement is very important for the client with pulmonary edema in order to promote reabsorption of fluid and reduce the risk of infection. Performing a head-to-toe or cardiac assessment would delay data collection on the priority system. The LPN/LVN would perform a focused assessment of the respiratory system and report findings to the RN before continuing to collect other data.
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