Which assessment data for a client with a urinary tract infection and sepsis indicates the client may be developing a complication of sepsis?

Normal ranges for arterial blood gases (ABGs) are as follows:

- pH: 7.35-7.45

- PaO2: 75-100 mm Hg

Normal ranges for platelet count are:

- Platelets: 150,000-400,000/mm^3

ABG: pH 7.36 (normal range 7.35-7.45), PaO2 80 mm Hg (normal range 75-100 mm Hg)

Temperature 100.8°F

Platelets 99,000/mm^3 (normal range 150,000-400,000/mm^3)

Urine culture positive for gram-negative bacteria

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is A

Explanation

Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.

Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.

Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.

Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.

A. Vasodilation and fluid shift out of the vascular space B. Platelet aggregation and thrombus formation C. Decreased blood glucose and oliguria D. Hypoxemia and anaerobic metabolism

Correct Answer is A

Explanation

Choice A reason: In sepsis, inflammatory mediators cause vasodilation and increased capillary permeability, leading to fluid leaking out of the vascular space, resulting in hypotension.

Choice B reason: Platelet aggregation and thrombus formation can occur in sepsis but are more related to disseminated intravascular coagulation (DIC) rather than directly causing hypotension.

Choice C reason: Decreased blood glucose and oliguria can be consequences of sepsis but are not the primary pathophysiological processes responsible for hypotension.

Choice D reason: Hypoxemia and anaerobic metabolism may result from the effects of sepsis on the body, including hypotension, but they are not the direct cause of hypotension.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client admitted for treatment of pneumonia and possible sepsis. Which information is most important for the nurse to report?

Correct Answer is A

Explanation

The nurse recognizes that a patient with sepsis is at risk to develop hypotension. Which pathophysiological process is responsible for this symptom?

Correct Answer is A

Explanation

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