The healthcare provider orders: Epinephrine 0.25 mg IV stat. Pharmacy provides: Epinephrine 0.1 mg/mL. How many mL will the nurse prepare to administer? Enter the number only. Round to one decimal place.

A. Increase 0.9% Normal Saline infusion to 250 mL/hr per protocol: The client’s low CVP and PAWP, hypotension, tachycardia, and dry mucous membranes indicate hypovolemia and dehydration, likely due to sepsis with fluid losses. Increasing isotonic fluid infusion helps restore intravascular volume, improve perfusion, and stabilize hemodynamics.

B. Administer Furosemide (Lasix) 20 mg IV push: Furosemide is contraindicated because it promotes diuresis and would worsen the client’s hypovolemia. The client’s low filling pressures and hypotension indicate severe fluid deficit, not overload. Administering Lasix could precipitate hypoperfusion, acute kidney injury, and cardiovascular collapse.

C. Collect UA for culture and sensitivity: Urinary tract infection is a common cause of sepsis in older adults. Obtaining a urine culture helps identify the causative organism and guide antibiotic therapy, making this order appropriate and necessary for diagnostic accuracy.

D. Collect blood cultures and start Vancomycin 1 gm IV: Blood cultures are essential before antibiotic administration to identify systemic infection sources. Starting broad-spectrum antibiotics like vancomycin promptly after collection aligns with sepsis management protocols and supports early infection control.

A. Obtain a bedside commode: A bedside commode may provide convenience and safety for clients at risk for falls, but the client’s vital signs are stable after ambulating to the bathroom, so a commode is not immediately necessary. This action is optional rather than a priority.

B. Suggest the client use a bedpan: Using a bedpan could limit mobility and independence unnecessarily. The client’s current stable vital signs indicate that bathroom privileges are safe, making bedpan use unnecessary at this time.

C. Allow continued bathroom privileges: The client’s oxygen saturation, pulse, and respiratory rate are all within normal limits after ambulation, indicating they tolerate activity well. Continuing bathroom privileges supports autonomy and is appropriate based on the current assessment.

D. Administer oxygen at 2 L/min: The client’s oxygen saturation is 96%, which is within normal range for most adults. Supplemental oxygen is not indicated for a stable, asymptomatic client, so administering oxygen is unnecessary and could be inappropriate.