A nurse is teaching a class about the steps of the inflammatory response. The nurse should include that which of the following is the first step in the inflammatory response?

A. "The MDS forms are provided to the facility with analysis of each resident's prescribed medications." While medication management is part of a resident’s overall care, the Minimum Data Set (MDS) primarily focuses on assessing a resident’s physical, cognitive, and psychosocial status rather than analyzing medication regimens.

B. "The MDS forms provide documentation of each resident's assessment, including their cognitive and physical status." The MDS is a standardized assessment tool used in long-term care facilities to evaluate residents' needs, including cognitive function, physical health, and psychosocial well-being. It helps guide individualized care planning and ensures compliance with federal regulations.

C. "The MDS forms are completed by the provider each month." The MDS is typically completed by trained nurses or interdisciplinary team members rather than only the provider. It is updated at specific intervals, such as upon admission, quarterly, annually, and when there is a significant change in a resident’s condition.

D. "The MDS forms are faxed to health care providers at the end of each quarter." MDS documentation is electronically submitted to the Centers for Medicare & Medicaid Services (CMS) rather than being faxed to individual healthcare providers. The data collected helps monitor care quality and facility compliance with federal guidelines.

A. T 38.6° C (101.5°F), oral. The client’s temperature has increased, which may indicate that the infection is progressing despite treatment. Persistent fever can contribute to dehydration, increased metabolic demand, and worsening systemic inflammation, all of which require further assessment and potential intervention.

B. Apical HR 108/min. The client’s heart rate has risen from 99/min to 108/min, which may be a compensatory response to fever, infection, or early signs of sepsis. Tachycardia combined with hypotension warrants close monitoring for worsening hemodynamic instability.

C. BP 112/54 mm Hg, supine. The blood pressure has decreased from 114/56 mm Hg to 112/54 mm Hg. While this is still within an acceptable range for some clients, the low diastolic pressure may indicate vasodilation due to sepsis or dehydration. If this trend continues or the client becomes symptomatic (e.g., dizziness, altered mental status), further intervention may be needed.

D. R 22/min. The respiratory rate has decreased from 32/min to 22/min, indicating improved respiratory status with oxygen therapy. This does not require follow-up as it falls within the normal range (12-20/min) and suggests a positive response to treatment.

E. Pulse oximetry 95% on 40% O₂ via face mask. The oxygen saturation has improved significantly from 85% on room air to 95% on supplemental oxygen. This suggests that oxygen therapy is effective, and no immediate follow-up is needed for this parameter.

F. Mucous membranes pink. The improvement from pale to pink mucous membranes indicates better oxygenation and perfusion, likely due to supplemental oxygen and improved respiratory function. This is a positive finding that does not require further intervention.