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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While individuals with rheumatoid arthritis may have an increased risk of infection due to the disease itself or the use of immunosuppressive medications, it does not pose as high a risk as intravenous lines for sepsis.
Choice B reason: A peripherally inserted central catheter (PICC) line, especially when used for total parenteral nutrition (TPN), presents a significant risk for infection due to the direct access to the bloodstream, making this client at the highest risk for sepsis.
Choice C reason: Asthma and bronchitis can lead to respiratory infections, but these conditions do not typically result in sepsis unless the infection becomes severe and systemic.
Choice D reason: Renal calculi (kidney stones) can cause infections; however, they are less likely to lead to sepsis compared to a central line.
Correct Answer is D
Explanation
The correct answer is d. Urine output 60 mL.
Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.
Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.
Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.
Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.
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