A client has a high risk for sepsis-induced shock. Which of the following changes in the client's status should the nurse immediately report to the physician?
A urine output of 40 mL/hour
A hemoglobin level of 12 gm%
A decrease in heart rate from 100 to 90 beats/minute
A statement that he/she feels "antsy."
The Correct Answer is A
Rationale:
A. A urine output of 40 mL/hour is below the expected minimum of 0.5 mL/kg/hr for an average adult and indicates possible early renal hypoperfusion, which is a critical sign of sepsis-induced shock. Reduced urine output is a key indicator of inadequate tissue perfusion and organ dysfunction, requiring immediate medical attention.
B. A hemoglobin level of 12 gm% is within the normal range for most adults and is not an immediate concern in the context of sepsis.
C. A decrease in heart rate from 100 to 90 beats/minute is not alarming in isolation and may represent a normal variation. In sepsis, tachycardia is more concerning than a mild decrease in rate.
D. Feeling "antsy" is subjective and non-specific. While changes in mental status are important, this vague statement alone does not indicate an urgent physiological change requiring immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Blood pressure of 92/50 mm Hg is the priority finding because it indicates hypotension, which may be a sign of internal bleeding or shock following blunt abdominal trauma. Maintaining perfusion to vital organs is the highest priority according to the ABCs (Airway, Breathing, Circulation). Early hypotension in trauma is a late and critical sign of blood loss, making this the most urgent concern.
B. Heart rate of 92/min is slightly elevated for an adolescent but not critically abnormal. While tachycardia can indicate early shock, it is a compensatory response and less immediately life-threatening than hypotension.
C. Abdominal pain rated 6/10 indicates tissue injury or internal trauma, but pain severity alone does not guide immediate life-saving interventions. Monitoring and pain management are important but secondary to assessing circulation.
D. Respiratory rate of 22/min is slightly elevated but within mild tachypnea range for an adolescent. While important to monitor for respiratory compromise, it is not as urgent as hypotension in the context of trauma.
Correct Answer is D
Explanation
Rationale:
A. Cryoprecipitates contain clotting factors such as fibrinogen, factor VIII, and von Willebrand factor. They are used to treat coagulation disorders, not to replace lost circulating volume in hypovolemic shock.
B. Platelets are administered for thrombocytopenia or platelet dysfunction to prevent or treat bleeding. While they are part of managing massive transfusions or coagulopathy, they do not restore oxygen-carrying capacity or intravascular volume in hypovolemic shock.
C. Albumin is a colloid solution that can expand plasma volume by drawing fluid into the intravascular space. It can be used in some cases of hypovolemia, but it does not provide oxygen-carrying capacity, which is critical when blood loss is significant.
D. Packed red blood cells (PRBCs) are the treatment of choice for hypovolemic shock caused by significant blood loss. PRBCs restore circulating volume and oxygen-carrying capacity, improving tissue perfusion and preventing organ failure. Administering PRBCs is a priority when hypotension and signs of shock are present due to hemorrhage.
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