A nurse is caring for a 73-year-old male client in the emergency department (ED).

Exhibits

It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

Choice A rationale

Cyanosis is a late sign of hypoxemia and not the most common initial manifestation of ARDS. It indicates severe oxygen deprivation but doesn’t typically appear first.

Choice B rationale

Diaphoresis, or excessive sweating, can occur with many conditions causing distress, but it’s not specifically the most common presenting symptom of ARDS. It's more of a nonspecific symptom of stress.

Choice C rationale

Somnolence, or drowsiness, might occur in severe respiratory distress when oxygen levels drop significantly, but it’s not the primary or most common presenting manifestation of ARDS.

Choice D rationale

Dyspnea, or difficulty breathing, is the hallmark of ARDS and the most common presenting symptom. It occurs due to the acute onset of severe hypoxemia caused by the underlying pathophysiology of ARDS.

Choice A rationale

Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.

Choice B rationale

Bloody fluid may indicate trauma or malignancy but not necessarily infection.

Choice C rationale

Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.

Choice D rationale

Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.