NCLEX-RN · Physiological Adaptation
Item 1 of 3 · Matrix / grid · Analyze Cues
| Temperature | 38.9 °C ↑ |
| Heart rate | 118 bpm ↑ |
| Blood pressure | 86/48 mmHg ↓ |
| Respiratory rate | 28 breaths/min ↑ |
| SpO₂ | 91% on 2 L nasal prongs ↓ |
A 68-year-old client admitted with community-acquired pneumonia has become increasingly confused over the past three hours.
For each finding, indicate whether it supports sepsis, supports fluid volume deficit alone, or supports both.
| Finding | Sepsis | Fluid volume deficit alone | Both |
|---|---|---|---|
| Temperature 38.9 °C | |||
| Lactate 4.2 mmol/L | |||
| Blood pressure 86/48 mmHg | |||
| WBC 19.4 ×10⁹/L | |||
| New-onset confusion |
One selection per row. Every row is scored independently — never leave one blank.