Your patient, post-operative from a gastrointestinal surgery, presents with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT.

Which of the following findings indicate that the patient is progressing to septic shock? Select all that apply:

Choice A rationale
Recurring chest pain can be a symptom of a serious condition such as a heart attack, which can occur if a blood clot forms in a vein deep inside the body, breaks off, and travels to the heart.
This is a potential complication of Deep Vein Thrombosis (DVT) and other vascular issues. Therefore, it’s important for the nurse to inquire about recurring chest pain in a patient with a past history of DVT and other vascular issues.
Choice B rationale
A peptic ulcer is a sore that develops on the lining of the stomach, upper small intestine, or lower esophagus. While peptic ulcers can cause discomfort and other symptoms, they are not typically associated with DVT or other vascular issues. Therefore, while it’s always important for the nurse to have a complete understanding of a patient’s health history, inquiring about a peptic ulcer may not be directly relevant to a patient with a past history of DVT and other vascular issues.
Choice C rationale
An aneurysm is a bulge or ballooning in the wall of an artery. Aneurysms can occur in any artery in the body, and they can be life-threatening if they rupture or dissect (tear)3. While aneurysms can be associated with certain vascular diseases, they are not typically associated with DVT3. Therefore, while it’s important for the nurse to be aware of a patient’s complete health history, inquiring about an aneurysm may not be directly relevant to a patient with a past history of DVT.
Choice D rationale
Rheumatoid arthritis is an autoimmune disease that causes inflammation in the joints. While it can cause a variety of symptoms and complications, it is not typically associated with DVT or other vascular issues. Therefore, while it’s always important for the nurse to have a complete understanding of a patient’s health history, inquiring about rheumatoid arthritis may not be directly relevant to a patient with a past history of DVT and other vascular issues.

Choice A rationale
Cramping of the toes is not typically associated with a positive Homans sign. Homans sign is a test used to check for deep vein thrombosis (DVT), a blood clot in a deep vein of the leg. While cramping can occur with DVT, it is not specific to this condition and can occur with many other conditions.
Choice B rationale
Blanching of the sole is not associated with a positive Homans sign. Blanching, or whitening of the skin, can occur with various conditions, but it is not a typical sign of DVT45.
Choice C rationale
Resisting dorsiflexion is not a typical response indicating a positive Homans sign. While pain or resistance during dorsiflexion of the foot can occur with various conditions, it is not a specific sign of DVT45.
Choice D rationale
Pain in the calf area during dorsiflexion of the foot (Homans sign) can indicate a positive sign for DVT. However, it’s important to note that Homans sign is not a reliable or definitive test for DVT. Other diagnostic tests, such as ultrasound, are needed to confirm the diagnosis.