A nurse is preparing to perform tracheostomy care for a client.
In which order should the nurse take the following steps?

(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Condition: Sepsis.

2 actions:

Administer a broad-spectrum antibiotic,

Perform a swab culture of the AVF site.

2 parameters:

White blood cell count,

Blood cultures.

Rationale for correct condition: Sepsis is indicated by the client's fever, elevated heart rate, and respiratory rate, combined with signs of infection at the AVF site. Chronic conditions like diabetes and renal disease increase sepsis risk. The symptoms and history align with systemic infection spreading from the AVF site. Sepsis requires immediate intervention to prevent severe complications. Elevated temperature and infection signs suggest systemic involvement.

Rationale for actions: Administering antibiotics is crucial to control the infection. Swab culture identifies the causative organism. Indwelling catheter is unnecessary here. Aspirin does not treat infection. Bed rest alone is insufficient. Monitoring WBC count tracks infection response. Blood cultures confirm sepsis diagnosis. Creatinine is less urgent for immediate management. Blood glucose is relevant but not immediate. AVF site circumference monitors local rather than systemic infection.

Rationale for parameters: WBC count indicates immune response. Blood cultures identify bacteria, confirming sepsis. Creatinine is routine but not urgent. Blood glucose tracks diabetes control, less immediate. AVF circumference monitors local inflammation. Cellulitis is localized, not systemic. AVF thrombosis lacks systemic signs like fever. Endocarditis requires specific cardiac symptoms.

Rationale for incorrect conditions: Cellulitis does not explain systemic symptoms. AVF thrombosis lacks systemic infection signs. Endocarditis has distinct cardiac symptoms absent here.

Choice A rationale

Platelets 60,000/mm³ is significantly below the normal range of 150,000 to 400,000/mm³, which can indicate a risk of bleeding and is a concern for a procedure like a liver biopsy.

Choice B rationale

Ammonia levels of 55 mcg/dL are within the normal range of 10 to 80 mcg/dL, so this value does not need to be reported.

Choice C rationale

Bilirubin 1.0 mg/dL is at the upper limit of the normal range of 0.3 to 1.0 mg/dL, but it does not necessarily indicate a significant risk for a liver biopsy.

Choice D rationale

Aspartate aminotransferase 34 units/L is at the upper limit of the normal range of 0 to 34 units/L, but it does not indicate a contraindication for the biopsy.