NCLEX RN· RN Medical Surgical Nursing · Basic Adult Health Care NCLEX Questions
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The nurse in the emergency department (ED) is caring for a 62-year-old male client. Item 3 of 6 Triage Note 1700: • The client was brought to the ED after collapsing on a tennis court. • Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Expert Explanatory Rationale
Correct Answer: multiple organ dysfunction.
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