The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). Which assessment data indicates the presence of SIRS?
1. Temperature 36.4°C, respiratory rate 22, pulse rate 112, and PaCO2 34
2. Temperature 38.4°C, respiratory rate 23, pulse rate 92, and PaCO2 31
3. Temperature 37.2°C, respiratory rate 24, pulse rate 102, and PaCO2 44
4. Temperature 38.8°C, respiratory rate 25, pulse rate 88, and PaCO2 48
2
Rationale 1: This data does not support the finding of SIRS.
Rationale 2: The definition of SIRS includes temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO2 less than 32 torr.
Rationale 3: This data does not support the finding of SIRS.
Rationale 4: This data does not support the finding of SIRS.
You might also like to view...
The Spiritual Perspective Scale can be used to measure:
a. spiritual wellness c. spirituality-related interactions b. harmony and interconnectedness d. spiritual distress
When the patient with a Salem sump tube for decompression complains of feeling full and has dyspnea and nausea, the initial intervention by the nurse should be to:
a. increase the amount of suction from low to high. b. notify the charge nurse. c. irrigate the tube with normal saline. d. pull the tube out about 3 inches.
The perinatal nurse includes a pain assessment as part of the postpartum care provided to each patient. This action helps to:
Select all answers that apply: A) Decrease the recovery time B) Decrease the risk of depression C) Increase the length of the hospital stay D) Decrease the patient's coping ability
Gauze dressings:
a. Have a non-stick surface b. Absorb drainage c. Allow observations of the wound d. Keep the wound moist