The nurse receives handoff of care report on four clients. Which client should the nurse assess first?

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11ecbb05_cbc5_5362_b433_d12903438f01_MD0009_00 Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response mediated by the release of large quantities of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue ischemia, infection (ie, sepsis), and shock and can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea (often associated with a low PaCO₂ value). Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes (eg, antibiotics for infection) as SIRS may be life-threatening (Option C). (Options A and B) Addressing a client's postoperative pain and nausea and further assessing a client with hyperglycemia and diabetes are important but are lower priorities than initiating care for SIRS. (Option D) A client with persistent diarrhea should have both total intake and output and recent electrolyte levels assessed, but signs of SIRS should be addressed first. Educational objective: Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response to inflammatory cytokine release from the inflammatory cascade (eg, trauma, tissue ischemia, infection [ie, sepsis]) that may rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. Clinical manifestations of SIRS include fever or hypothermia, tachypnea or low PaCO₂, tachycardia, and leukocytosis or leukopenia.

The Nurse Receives Handoff of Care Report on Four Clients