A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply
A) Temperature of 102° F
B) Heart rate of 120 beats/minute
C) Respiratory rate of 24 breaths/minute
D) PaCO2 of 42 mm Hg
E) Blood pressure of 120/80 mm Hg
A, B, C
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Two or more of the following characterize sepsis: temperature greater than 100.4° F (38° C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm3, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator.
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