The nurse prepares to do a focused assessment on a client who was successfully treated for bleeding esophageal varices yesterday.
Which body system should the nurse prioritize?

Sepsis requires a focused assessment of systemic perfusion and the inflammatory response. Knowledge of the Sequential Organ Failure Assessment criteria is necessary. The nurse must prioritize assessments that reflect respiratory function, renal perfusion, and peripheral microvascular status to detect early deterioration.

Choice A rationale

Sepsis often leads to increased capillary permeability and acute lung injury. Assessing breath sounds allows the nurse to detect adventitious sounds like crackles, which may indicate the development of pulmonary edema or progressing respiratory distress or infection.

Choice B rationale

Urine output is a primary indicator of organ perfusion. In sepsis, decreased output less than 0.5 mL per kg per hr suggests inadequate renal blood flow or acute kidney injury resulting from systemic hypotension and inflammatory damage.

Choice C rationale

While glucose levels can fluctuate during the stress response of sepsis, it is not a primary component of a focused sepsis assessment compared to hemodynamic markers. Hyperglycemia is common but does not specifically define the septic state.

Choice D rationale

Skin temperature and capillary refill provide information about peripheral perfusion. In early sepsis, skin may be warm due to vasodilation, while late sepsis often presents with cool, clammy skin as the body shunts blood to organs.

Choice E rationale

The date of the last bowel movement is a part of a general gastrointestinal assessment but is not a priority in a focused sepsis evaluation. It does not provide immediate data regarding systemic inflammatory response or perfusion..

Identifying appropriate placement for infectious clients requires understanding transmission-based precautions. Tuberculosis is an airborne pathogen requiring specialized ventilation to prevent the spread of droplet nuclei. Knowledge of negative pressure systems and environmental safety standards is essential for preventing nosocomial transmission to others.

Choice A rationale

Placing a client with active tuberculosis in a semi-private room violates airborne precautions. This increases the risk of horizontal transmission to immunocompromised roommates via microscopic droplet nuclei that remain suspended in the air for several hours.

Choice B rationale

Airborne infection isolation rooms require a minimum of 6 to 12 air exchanges per hour. Exhausting air directly outdoors or through HEPA filters prevents contaminated air from recirculating into common hallways or other patient care areas.

Choice C rationale

Admission to an intensive care unit is reserved for hemodynamically unstable clients or those requiring advanced mechanical ventilation. Tuberculosis alone is not an indication for critical care unless the client exhibits acute respiratory failure or septic shock.

Choice D rationale

While proximity to the nurses' station allows for frequent observation, it does not address the physiological requirement for negative pressure ventilation. Standard medical-surgical rooms lack the engineering controls necessary to contain airborne bacilli within the specific room.