In the morning, a nurse receives a report on four pediatric clients, each of whom has some form of fluid volume excess. Which child should the nurse check first? The child with:
1. Periorbital edema, normal respiratory rate.
2. Tachypnea and pulmonary congestion.
3. Dependent and sacral edema, regular pulse.
4. Hepatomegaly, normal respiratory rate.
2
Rationale:
1. The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.
2. A child with respiratory distress should be the first client the nurse checks after receiving the report.
3. The child with dependent and sacral edema is more stable than the child with tachypnea and pulmonary congestion.
4. The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.
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