The nurse is reviewing orders received for a client diagnosed with sepsis. Which order should the nurse question?

Administer oxygen via mask.

Obtain serum lactate level.

Infuse 0.9% NS at 50 mL/hr.

Obtain blood and urine cultures.

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering oxygen via mask is appropriate for a client with sepsis who may have compromised oxygenation.

Choice B reason: Obtaining a serum lactate level is important in sepsis as it can indicate the severity of the condition and guide treatment.

Choice C reason: An infusion rate of 0.9% Normal Saline at 50 mL/hr may be questioned because clients with sepsis may require more aggressive fluid resuscitation.

Choice D reason: Obtaining blood and urine cultures is essential before starting antibiotics to identify the causative organism in sepsis.

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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.

A. Assess for hematuria. B. Monitor temperature. C. Evaluate skin turgor. D. Administer heparin.

Correct Answer is D

Explanation

Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.

Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.

Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.

Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.

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The nurse is reviewing orders received for a client diagnosed with sepsis. Which order should the nurse question?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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