You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?
A) The client feels restless and hungry.
B) The client exhibits an increased urinary output.
C) The client's heart rate is greater than 90 beats/minute.
D) The client's respiratory rate is less than 20 breaths/minute.
C
Feedback:
A heart rate greater than 90 beats/minute or a respiratory rate greater than 20 breaths/minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.
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