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Nursing roles in Patient assessment and documentation
Nursing roles in Patient assessment and documentation ( 6 Questions)
A nurse is assessing a client who has been admitted with suspected sepsis.
Which finding should the nurse report to the provider immediately?
This is a sign of fever, which is a common symptom of sepsis, but not as urgent as hypotension.
This is a sign of tachycardia, which is a compensatory mechanism to maintain cardiac output in sepsis, but not as urgent as hypotension.
A blood pressure of 90/60 mmHg indicates hypotension, which is a sign of septic shock and requires immediate intervention. Hypotension results from vasodilation and fluid loss due to the systemic inflammatory response to infection.
This is within the normal range for adults and does not indicate respiratory distress.
Blood pressure of 90/60 mmHg
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which is a sign of septic shock and requires immediate intervention. Hypotension results from vasodilation and fluid loss due to the systemic inflammatory response to infection.
Incorrect options:
A) Temperature of 38.5°C (101.3°F) - This is a sign of fever, which is a common symptom of sepsis, but not as urgent as hypotension.
B) Heart rate of 110 beats per minute - This is a sign of tachycardia, which is a compensatory mechanism to maintain cardiac output in sepsis, but not as urgent as hypotension.
D) Respiratory rate of 22 breaths per minute - This is within the normal range for adults and does not indicate respiratory distress.