SOLVED1616

1630 – The nurse is performing an assessment of the client. The client is arousable but lethargic and reports soreness and stiffness in their jaw. Lungs are clear; respirations are fast but unlabored. Abdomen is soft and nondistended; bowel sounds hypoactive in all quadrants. Urinary catheter remains in place draining brown urine. Dressing to surgical site is dry and intact. Right leg with good sensation, and client can wiggle their toes. Bilateral extremities cool to the touch; capillary refill 3 seconds. Lactated Ringer’s infusing at 125 mL/hr to a left arm IV catheter. Vital signs are: temperature 39.2Ëš C (102.5Ëš F), heart rate 154/min, respirations 24/min, blood pressure 94/62 mm Hg, and SpOâ‚‚ 90% on room air. Based on the assessment findings, which of the following conditions should the nurse suspect the client is most likely experiencing? Avascular necrosis Dehydration Sepsis Pain Malignant hyperthermia Tetanus Fat embolism syndrome
SCIENCE
HEALTH SCIENCE
NURSING

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