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Difficulty: MediumReduction of Risk Potential

An older adult client is receiving care on a medical unit for a diagnosed urinary tract infection. During a routine assessment, the practical nurse (PN) observes that the client's skin is flushed and warm to the touch, and the client is unusually drowsy. Current vital signs reveal a blood pressure of 94/5694/56 mm Hg, a heart rate of 114114 beats/min, and a respiratory rate of 2424 breaths/min. A review of the electronic health record shows a newly resulted serum lactic acid level of 4.64.6 mmol/L (reference range: 0.50.5 to 2.22.2 mmol/L). What is the priority action for the PN?

  1. Immediately notify the registered nurse of the client's clinical presentation and laboratory results.Answer
  2. B
    Ensure the lactic acid result is documented in the chart for the healthcare provider to review during rounds.
  3. C
    Provide the client with oral fluids and recheck the vital signs in one hour to verify the downward trend.
  4. D
    Initiate a rapid intravenous fluid bolus of normal saline to improve the client's blood pressure.

Answer

The priority action is to immediately notify the registered nurse so that advanced assessment and rapid medical interventions can be initiated.
The correct action is to immediately escalate the situation to the registered nurse. The combination of an existing infection, altered mental status, tachycardia, hypotension, and a critically high lactic acid level strongly indicates that the client is developing severe sepsis. This is a medical emergency. The PN's role in risk reduction is to recognize these critical physiological deviations and rapidly communicate them to the RN, who can then coordinate advanced interventions such as fluid resuscitation and broad-spectrum antibiotics.

Step-by-Step Solution

1
Analyze the client's vital signs and physical assessment findings.
The client has hypotension, tachycardia, tachypnea, and altered mental status (drowsiness).
These findings represent a significant change in baseline and are classic indicators of systemic inflammatory response and potential shock.
2
Evaluate the laboratory data provided in the scenario.
The lactic acid level of 4.6 mmol/L is critically elevated above the normal range of 0.5 to 2.2 mmol/L.
Elevated lactic acid indicates poor tissue perfusion and cellular hypoxia, confirming a high risk for severe sepsis.
3
Determine the appropriate intervention within the PN scope of practice.
The situation requires immediate clinical judgment, advanced assessment, and likely intravenous medication administration.
Because the required interventions exceed the independent scope of the PN, the highest priority action to reduce client risk is immediate escalation to the RN.

Key Concept

Recognition of Sepsis and Scope of Practice Escalation
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Topics

Reduction of Risk Potential

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