The nurse suspects that a client has an infection. Which assessment findings support that suspicion?
1. Heart rate of 110 and rapid, shallow respirations
2. Temperature of 37°C and increased heart rate
3. Respirations of 12/minute and increased heart rate
4. Respirations of 10/minute and decreased heart rate
Correct Answer: 1
Rationale 1: Clients experiencing infection present with an increased heart rate and rapid, shallow respirations.
Rationale 2: This temperature is normal.
Rationale 3: This is a normal respiratory rate.
Rationale 4: Clients experiencing inflammation and infection do not present with a decreased heart rate or respirations.
Global Rationale: The systemic manifestations of inflammation associated with an infection are elevated temperature above 39°C (102°F), pulse rate greater than 90 beats/minute, respirations greater than 20 breaths/minute, and a white blood cell count greater than 12,000/mm3.
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