In the morning, a nurse receives a report on four pediatric clients who have some form of fluid-volume excess. Which client should the nurse assess first?
1. A client with periorbital edema, normal respiratory rate
2. A client with tachypnea and pulmonary congestion
3. A client with dependent and sacral edema, regular pulse
4. A client with hepatomegaly, normal respiratory rate
Correct Answer: 2
Rationale: A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.
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