The nurse is caring for a client who is being ruled out for systemic inflammatory response syndrome (SIRS). Which assessment findings meet the SIRS criteria? (Select all that apply)

Choice A reason: Inserting a Foley catheter is an essential nursing intervention to monitor renal perfusion via hourly urine output during shock. However, this is a monitoring tool rather than a corrective action. In the progressive stage of shock, restoring systemic perfusion and blood pressure takes precedence over the initiation of output monitoring.

Choice B reason: Initiating norepinephrine is the priority because the client is demonstrating signs of the progressive stage of shock, characterized by a rapid decline in cardiac output and blood pressure. Norepinephrine is a potent vasoconstrictor and alpha-1 agonist that increases systemic vascular resistance and mean arterial pressure to maintain vital organ perfusion.

Choice C reason: Administering an intravenous push of adenosine is contraindicated in this clinical scenario. Adenosine is an antiarrhythmic medication used specifically for the conversion of supraventricular tachycardia to sinus rhythm. Giving it to a client with decreasing cardiac output and hypotension would further compromise their hemodynamic stability and could lead to cardiac arrest.

Choice D reason: Obtaining blood cultures is a critical step in the management of septic shock to guide antimicrobial therapy. However, when a client's hemodynamic status is rapidly deteriorating (evidenced by falling systolic pressure and cardiac output), the immediate priority is physiological stabilization through vasopressors or fluids rather than diagnostic laboratory collection.

Choice A reason: Marking the expiration date on a calendar is a proactive and correct safety measure. Epinephrine loses its potency over time, and a patient must ensure the medication is current to be effective during a life threatening anaphylactic event where every second is critical for survival.

Choice B reason: This statement is incorrect and indicates a need for further teaching. Epinephrine is a short acting medication that provides temporary relief from airway constriction and vasodilation. A biphasic reaction can occur, where symptoms return after the initial dose wears off, requiring immediate professional medical observation and stabilization.

Choice C reason: Epinephrine autoinjectors are designed for emergency use and can be effectively administered through most clothing, such as jeans or leggings. This design allows for rapid delivery of the medication without the delay of undressing, which is essential during a rapidly progressing allergic reaction.

Choice D reason: Patients are often prescribed a twin pack because a single dose may not be sufficient to reverse severe anaphylaxis, or a second dose may be needed if emergency services are delayed. Carrying two injectors ensures the patient has a backup for refractory symptoms or mechanical failure.