A client presents to the emergency department with a history of edema in the lower extremities. What information is most important to obtain before determining the nurse's next action?
1. Ask the client for his or her position of comfort.
2. Auscultate breath sounds.
3. Inspect the skin for pallor.
4. Palpate the thorax.
Ask the client for his or her position of comfort.
Rationale: When the client has edema in the lower extremities, the nurse is concerned about right-sided heart failure as fluid backs up into the peripheral circulation. If the position of comfort is upright with an inability to lie supine, pulmonary hypertension is present; the nurse needs to notify a care provider immediately. Pallor, breath sounds, and palpating the thorax can also indicate respiratory distress and obstruction, but right-sided heart failure is the priority.
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