A 72-year-old client is admitted from a skilled nursing facility with altered mental status and a productive cough. The nurse performs an assessment and documents the following findings: Temperature 101.8°F (38.8°C), heart rate 94 beats/min, respiratory rate 24 breaths/min, blood pressure 118/72 mm Hg, and WBC count 14,200/mm3. Based on the SIRS criteria, which findings indicate this client meets criteria for systemic inflammatory response syndrome? Select all that apply.

A. PaCO₂ of 45 mm Hgis incorrect because 45 mm Hg is at the upper limit of normal (normal 35–45 mm Hg). In early shock, clients often hyperventilate, causing a decreased PaCO₂. A value of 45 mm Hg alone does not specifically indicate irreversible shock.

B. Respirations 30/minis incorrect because tachypnea is a compensatory mechanism seen in the early (compensatory) stage of shock. The body attempts to improve oxygen delivery by increasing respiratory rate. This finding alone does not indicate irreversible shock.

C. Urine output 15 mL/hris correct because severely decreased urine output indicates significant renal hypoperfusion and possible acute kidney injury. In the irreversible (refractory) stage of shock, prolonged tissue hypoxia leads to organ failure. Oliguria (less than 30 mL/hr in adults) is a critical sign of worsening shock, and 15 mL/hr reflects severe compromise and progression toward multi-organ failure.

D. Blood pressure of 100 mm Hg systolicis incorrect because although this may be slightly low depending on baseline, it does not necessarily indicate irreversible shock. In early shock, blood pressure may remain near normal due to compensatory vasoconstriction. Profound, persistent hypotension despite interventions is more consistent with the irreversible stage.

A. ARDS and hypoxemia can lead to multi-organ hypoperfusion, including renal dysfunction. Monitoring BUN and creatininehelps assess for early signs of acute kidney injury, which is important in critically ill patients.

B. The client is restless and anxious, which can worsen oxygen consumption and respiratory distress. Sedatives may be prescribed to reduce anxiety and improve oxygenation, especially if non-invasive measures are insufficient. Sedation must be carefully titrated to avoid respiratory depression.

C.In ARDS, the head of the bed is usually elevated(30–45°) to improve oxygenation, reduce work of breathing, and prevent aspiration. Lowering the bed would increase risk of hypoxemia and aspiration.

D. Oxygen therapy is essential in ARDSto correct hypoxemia. Humidification prevents airway dryness, irritation, and mucus plugging, which are common in patients with shallow, rapid breathing.

E. Frequent auscultation helps the nurse monitor for changes in lung sounds, including worsening crackles, wheezing, or absent breath sounds, which may indicate progression of pulmonary edema or complications.