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

Temperature 99.6°F

Skin flushed with capillary refill <3 seconds

Renal output 45 mL/hr

Arrhythmias

Answer and Explanation

The Correct Answer is D

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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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. Oral temperature of 99.8°F (37.7°C) B. Post-operative hemoglobin of 10.9 g/dL (normal range: 12-16 g/dL) C. Client report of pressure sensation at the incision site D. Client report of 5/10 pain at the incision site

Correct Answer is C

Explanation

Choice A reason: An oral temperature of 99.8°F (37.7°C) post-operatively may not be unusual and does not necessarily indicate a complication.

Choice B reason: A post-operative hemoglobin of 10.9 g/dL is slightly below the normal range but may be expected after surgery due to blood loss.

Choice C reason: A client reporting a pressure sensation at the incision site could indicate bleeding or swelling under the incision, which can be a sign of a hematoma, a serious complication that needs immediate attention.

Choice D reason: Pain at the incision site is expected post-operatively and can be managed with pain relief measures.

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

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