Complete the diagram by choosing the condition the client is most likely experiencing, 2 actions to take and 2 parameters to monitor.
Actions to takeSelect 2
Draw blood cultures, then give the first broad-spectrum IV antibiotic as soon as possible✓ Correct
Infuse prescribed IV isotonic fluids to raise the blood pressure✓ Correct
Give an oral antipyretic and recheck the vital signs in four hours✗ Incorrect
Restrict IV fluids to prevent fluid overload✗ Incorrect
Hold antibiotics until the culture results are available✗ Incorrect
Condition most likely experiencingSelect 1
Septic shock✓ Correct
Hypovolemic shock from bleeding✗ Incorrect
Anaphylactic shock✗ Incorrect
Cardiogenic shock✗ Incorrect
Parameters to monitorSelect 2
Blood pressure and heart rate✓ Correct
Urine output✓ Correct
Serum cholesterol level✗ Incorrect
Calf circumference✗ Incorrect
Visual acuity✗ Incorrect
Answer
Actions to take: Draw blood cultures, then give the first broad-spectrum IV antibiotic as soon as possible; Infuse prescribed IV isotonic fluids to raise the blood pressure · Condition most likely experiencing: Septic shock · Parameters to monitor: Blood pressure and heart rate; Urine output
Rationale
A spreading infected incision with fever, a fast heart rate and respiratory rate, a high white blood cell count, new confusion and a systolic pressure under 90 mm Hg describes sepsis that has progressed to septic shock. A stable hemoglobin, no allergen exposure, clear lungs and flat neck veins argue against bleeding, anaphylaxis or a pump problem. Treatment is prompt antibiotics after cultures and IV fluids to restore perfusion, while blood pressure, heart rate and urine output show whether organs are being perfused.
RememberSuspected sepsis: cultures, then antibiotics fast, fluids for pressure, and watch perfusion.
Sources
Sources marked “Adapted from” are licensed under CC BY 4.0. We changed the material: its facts are rewritten into an original question, answer options and rationale. The original authors and publishers do not endorse SwipeExam.
About Sepsis (Source: CDC)Centers for Disease Control and Prevention (CDC) · License: CDC content (credit required) · Retrieved · Treatment; Diagnosis
Shock (MedlinePlus health topic)MedlinePlus, National Library of Medicine · License: US government work (public domain) · Retrieved · Summary: Shock
Sepsis (MedlinePlus health topic)MedlinePlus, National Library of Medicine · License: US government work (public domain) · Retrieved · Summary: Sepsis
Adapted from Open RN Nursing Pharmacology, 2nd edition: Chapter 3 AntimicrobialsOpen RN (Chippewa Valley Technical College) · License: CC BY 4.0 · Retrieved · Basic Concepts Related to Antimicrobial Therapy › Culture and Sensitivity; Assessment › First Think WHY?; Broad-Spectrum vs. Narrow-Spectrum Antimicrobials › RECAP · 2nd edition, 2023
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