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Report: 34-year-old client reports being sick with influenza. Admitted to hospital two days ago with a diagnosis of RLL pneumococcal pneumonia. Previous night shift reports the client has been awake, alert, and oriented through the evening. Scattered rhonchi and a productive cough with small amounts of yellow sputum. VSS. Client has reported no appetite and has not slept well. 0800: Client restless and confused. Skin flushed and hot. Client voiding approximately 400 mL per shift, fine crackles in both bases, wheezes present in right lung field. Health Care Provider Orders: O2 at 3L per nasal cannula, IV of 0.9 NS at 100 mL/hour Levofloxacin 500 mg in 0.9% NS 100 mL IV every 24 hours Albuterol per nebulizer every 6 hours Methylprednisolone 125 mg IV every 6 hours Vital Signs: Measurement 0400 0800 Temp (oral) 99°F (37°C) 102°F (33.8°C) HR 88 128 BP 116/78 82/56 RR 20 34 SpO2 on 3L/NC 94% 86% Laboratory Results: Q2: Which 4 clinical findings and information from the client’s history and current assessment indicate this client is septic? Client Findings â–¡ Glucose 144 mg/dL (8 mmol/L) â–¡ WBC 16,000/mm3 (16 X 109 /L) â–¡ Productive cough â–¡ BP 82/56 â–¡ Skin hot and dry
SCIENCE
HEALTH SCIENCE
NURSING

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