A nurse is caring for a client with septic shock. The client’s blood pressure is 80/50 mm Hg, and lactate levels are elevated. Which intervention is the nurse’s priority?

Choice A reason: IV antibiotics are critical in septic shock to treat the underlying infection, but they take hours to act. Hypotension (80/50 mm Hg) and elevated lactate indicate tissue hypoperfusion, requiring immediate restoration of blood pressure. Vasopressors address shock more rapidly, making antibiotics secondary in the acute stabilization phase.

Choice B reason: Septic shock with blood pressure of 80/50 mm Hg and elevated lactate indicates severe hypoperfusion and tissue hypoxia. Vasopressor therapy, like norepinephrine, restores blood pressure, improving organ perfusion. The ABCDE approach prioritizes circulation, making vasopressors the immediate intervention to prevent organ failure and death in this critical condition.

Choice C reason: Obtaining blood cultures identifies the causative organism in septic shock, guiding antibiotic therapy. However, it does not address immediate hypotension and hypoperfusion, indicated by low blood pressure and high lactate. Vasopressors stabilize circulation first, making cultures a secondary step in the acute management of septic shock.

Choice D reason: IV corticosteroids may be used in refractory septic shock to support adrenal function, but they are not the first-line intervention. Hypotension and elevated lactate require immediate vasopressor therapy to restore perfusion. Corticosteroids are adjunctive and slower-acting, making them less critical than vasopressors in the initial stabilization of septic shock.

Choice A reason: Blood pressure of 110/70 mm Hg is within normal range and does not indicate hypovolemic shock, which typically presents with hypotension (e.g., <90/60 mm Hg). Early shock may have normal blood pressure, but tachycardia (heart rate 120 beats/min) is a more sensitive indicator of compensatory response to volume loss.

Choice B reason: Heart rate of 120 beats/min indicates tachycardia, a hallmark of hypovolemic shock. In trauma, blood loss reduces circulating volume, triggering sympathetic activation to increase heart rate, compensating for decreased cardiac output. This is the most indicative finding, as it appears early and reflects the body’s response to hypovolemia.

Choice C reason: Warm, dry skin is not typical of hypovolemic shock, which causes cool, clammy skin due to vasoconstriction from sympathetic activation. Warm skin may occur in distributive shock (e.g., sepsis). Tachycardia is a more specific indicator of hypovolemia, making this finding incorrect for the suspected condition.

Choice D reason: Urine output of 40 mL/hr is within normal range (30-50 mL/hr) and does not indicate hypovolemic shock, which typically reduces output (<30 mL/hr) due to decreased renal perfusion. Tachycardia (120 beats/min) is a more immediate and sensitive sign of hypovolemia, making urine output less indicative in early shock.