A nurse is assessing a client who has an infection.
Which of the following findings is a manifestation of sepsis? (Select all that apply.)

Choice A rationale:

Tenderness, redness, and swelling at the incision site can indicate an infection or transplant rejection, both of which require immediate medical attention to prevent further complications.

Choice B rationale:

Swelling in the lower extremities (edema) can be a sign of fluid retention, which may indicate kidney dysfunction or transplant rejection, necessitating prompt evaluation and intervention.

Choice C rationale:

Elevated blood pressure (180/90 mm Hg) can be a sign of transplant rejection, as the body may be responding to the new organ as a foreign object, leading to increased blood pressure.

Choice A rationale

Obtaining a peak flow reading provides information about the severity of asthma, but it is not the immediate priority during an acute exacerbation.

Choice B rationale

Administering an inhaled glucocorticoid can help in managing inflammation, but it takes time to work and is not the immediate priority.

Choice C rationale

Determining the cause of the acute exacerbation is important for long-term management but is not the immediate priority.

Choice D rationale

Administering a short-acting B2-agonist (SABA) is the priority because it provides rapid bronchodilation, helping to alleviate the airway obstruction quickly.