Exhibits

Based on the client record and Surviving Sepsis Campaign Bundle, the nurse should implement which intervention to restore adequate perfusion at this time?

A. Potassium 10 meq IV mini bag: The potassium level is at the lower end of the normal range (3.5 mEq/L), but it is not critically low. Potassium supplementation may be needed, but it is not as urgent as managing the elevated INR and low platelet count.

B. Warfarin 5mg by mouth: The patient's INR is elevated at 5.0 (normal range: 2.0-3.0), which significantly increases the risk of bleeding, especially with low platelet levels (50,000/mm3, normal range: 150,000-450,000/mm3). Given the critical low platelets and elevated INR, this order should be brought to the provider's attention to reduce the bleeding risk.

C. Regular insulin 5 units subcutaneously: The patient’s blood glucose is elevated at 240 mg/dL, but insulin administration at 5 units is appropriate for the patient's condition and not an immediate concern compared to the bleeding risk from Warfarin.

D. Discontinue indwelling catheter: The catheter is scheduled for discontinuation, but this is not as urgent as addressing the bleeding risk associated with the elevated INR and low platelet count.

A. Cefepime 2grams IV every 12 hours: Cefepime is a broad-spectrum antibiotic, and the patient’s clinical signs, including fever, elevated WBC count, and confusion, suggest a possible infection. Immediate administration of antibiotics is critical to treat any potential infection.

B. Stat lactate level: The elevated lactate level (7.0 mmol/L) is concerning for tissue hypoxia or sepsis. Monitoring lactate levels helps assess the severity of the infection or potential sepsis, and obtaining this level stat is necessary to guide further treatment.

C. Fingerstick glucose every 6 hours: While monitoring blood glucose is important, it is not the highest priority in this acute situation, especially with more pressing concerns like infection and dehydration. However, it will be monitored regularly, as indicated in the provider's orders.

D. Obtain a set of blood cultures: Blood cultures are essential to identify the causative organism if the patient has an infection. With signs of systemic infection and elevated WBC, blood cultures should be obtained to determine the appropriate treatment.

E. Discontinue indwelling catheter: Although removing the catheter is important to reduce the risk of infection (especially with cloudy urine), it is not an immediate priority compared to addressing infection, sepsis, and fluid balance.

F. Discontinue Furosemide: While discontinuing Furosemide may be important due to the patient’s low blood pressure and potential fluid imbalance, it is not the most urgent intervention compared to starting antibiotics, correcting lactate levels, and fluid resuscitation.

G. 1000mL Lactated Ringer's at 170mL/hr: Given the patient’s potential sepsis and dehydration from diuresis, initiating IV fluid resuscitation with Lactated Ringer’s is a priority. This helps restore circulatory volume and supports organ function.