The nurse is admitting a client diagnosed with a urinary tract infection (UTI) and sepsis. Which intervention would the nurse consider a priority?

Assess temperature.

Monitor urine output.

Administer antibiotics.

Evaluate current CBC (Complete Blood Count).

Answer and Explanation

The Correct Answer is C

Choice A reason: While assessing temperature is important for monitoring infection, it is not the immediate priority in the treatment of UTI and sepsis.

Choice B reason: Monitoring urine output is crucial for a UTI but does not address the systemic infection that sepsis represents.

Choice C reason: Administering antibiotics is the most critical intervention for a client with sepsis due to a UTI, as it directly addresses the underlying infection and can be life-saving.

Choice D reason: Evaluating the current CBC is important for understanding the client's baseline and response to infection but is secondary to the administration of antibiotics.

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Correct Answer is C

Explanation

Choice A reason: The ABG values provided are within normal limits and do not indicate a complication of sepsis.

Choice B reason: A temperature of 100.8°F suggests an infection but is not specific enough to indicate a complication of sepsis.

Choice C reason: A platelet count of 99,000/mm3 is below the normal range and can indicate a complication of sepsis known as disseminated intravascular coagulation (DIC), which is a serious condition that can lead to severe bleeding or blood clots.

Choice D reason: A urine culture positive for gram-negative bacteria indicates an infection, which could be the source of sepsis, but it does not specifically indicate a complication of sepsis.

A. Temperature 99.6°F B. Skin flushed with capillary refill <3 seconds C. Renal output 45 mL/hr D. Arrhythmias

Correct Answer is D

Explanation

Choice A reason: A temperature of 99.6°F is a mild fever and not specifically indicative of the late phase of septic shock.

Choice B reason: Skin that is flushed with a capillary refill of less than 3 seconds does not suggest the late phase of septic shock, which would typically present with poor perfusion.

Choice C reason: A renal output of 45 mL/hr is within the normal range (0.5-1 mL/kg/hr for adults) and does not necessarily indicate the late phase of septic shock.

Choice D reason: Arrhythmias can be a sign of the late phase of septic shock as they indicate cardiac dysfunction, which is a result of decreased tissue perfusion and can lead to multiple organ failure.

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The nurse is admitting a client diagnosed with a urinary tract infection (UTI) and sepsis. Which intervention would the nurse consider a priority?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When assessing a client with sepsis, which finding would be consistent with the late phase of septic shock?

Correct Answer is D

Explanation

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