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The Nurse Is Caring for a Client with Systemic Inflammatory

Question 18

Multiple Choice

The nurse is caring for a client with systemic inflammatory response syndrome (SIRS) . Which assessment finding would the nurse anticipate? Select all that apply.


A) A white blood cell (WBC) count less than 3,000 cells/mm3 or greater than 10,000 cells/mm3
B) A heart rate of greater than 90 beats per minute
C) A respiratory rate of greater than 16 respirations per minute
D) A body temperature of less than 36°C or greater than 38°C
E) The presence of greater than 20% immature neutrophils

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