A client with suspected sepsis reports to the nurse they have a headache, feel hot, and are having blurry vision. What is the priority action by the nurse?

Choice A reason: Anaphylaxis triggers a massive systemic release of histamine and leukotrienes, leading to profound smooth muscle contraction in the bronchioles. This bronchoconstriction, along with mucosal edema, results in narrowed airways. Audible wheezing on inspiration and expiration reflects this high velocity airflow through constricted passages, signaling an imminent respiratory compromise.

Choice B reason: A decreased respiratory rate is not typical in the early stages of anaphylactic shock. Instead, the patient usually presents with tachypnea as a compensatory mechanism for hypoxia and respiratory distress. A decreasing respiratory rate in this context would be a late, ominous sign of impending respiratory failure and exhaustion.

Choice C reason: Anaphylactic shock is characterized by profound vasodilation and increased capillary permeability, which leads to a significant drop in systemic vascular resistance. Therefore, the nurse would expect to find hypotension rather than increased blood pressure. Hypertension is inconsistent with the pathophysiology of distributive shock associated with anaphylactic reactions.

Choice D reason: Rhonchi are coarse sounds typically caused by secretions in the larger airways. While some mucus production occurs, the primary respiratory hallmark of anaphylaxis is the constriction of the lower airways (wheezing) and upper airway edema (stridor). Rhonchi are more characteristic of conditions like chronic bronchitis or pneumonia.

Choice A reason: Irritable bowel syndrome is a functional gastrointestinal disorder that affects the large intestine but does not typically involve systemic inflammation or significant immunosuppression. While uncomfortable, it does not predispose a relatively young patient to the profound infectious vulnerability required for the development of septic shock.

Choice B reason: Chemotherapy agents frequently induce myelosuppression, specifically neutropenia, which severely compromises the host's immune surveillance and response. An older adult with a diminished absolute neutrophil count is highly susceptible to opportunistic infections that can rapidly escalate into systemic inflammatory response syndrome and subsequent septic shock.

Choice C reason: Being 20% above ideal body weight indicates overweight status or mild obesity. While chronic obesity can be associated with low-grade systemic inflammation and long-term metabolic risks, it is not an independent, acute risk factor for sepsis that carries the same weight as active pharmacological immunosuppression.

Choice D reason: While advanced age is a risk factor for infection, the use of beta blockers for hypertension does not inherently suppress the immune system. Although these medications might mask compensatory tachycardia during the early stages of shock, they do not increase the physiological risk of developing an infection.