A nurse is evaluating an older adult client hospitalized for a severe soft tissue infectio… — NCLEX-RN

A nurse is evaluating an older adult client hospitalized for a severe soft tissue infection. Over the past $4$ hours, the client's mentation has declined from alert to profoundly lethargic.

The current assessment reveals the following parameters:

Assessment Parameter	Client Value
Blood pressure	$82/48$ mm Hg
Heart rate	$134$ beats/min (weak, thready)
Respiratory rate	$28$ breaths/min
Oxygen saturation	$94\%$ on $2$ L/min via nasal cannula
Urine output	$15$ mL over the past $2$ hours

Arterial blood gas (ABG) values are as follows:

ABG Parameter	Client Value
pH	$7.25$
PaCO $_2$	$31$ mm Hg
PaO $_2$	$86$ mm Hg
HCO $_3^-$	$13$ mEq/L

Which of the following is the priority nursing action for this client?

Commencing aggressive volume replacement with an isotonic crystalloid solutionAnswer
B
Increasing oxygen delivery via non-rebreather mask to reverse the respiratory acidosis
C
Attaching a vasoactive medication infusion to immediately increase systemic vascular resistance
D
Hanging the prescribed intravenous antimicrobial therapy to eliminate the underlying infection source

Answer

The priority action is to commence aggressive volume replacement with an isotonic crystalloid solution.

The client is exhibiting classic signs of septic shock, including profound hypotension, tachycardia, oliguria, and altered mentation. The arterial blood gas reveals a partially compensated metabolic acidosis, likely resulting from lactic acid accumulation due to severe tissue hypoperfusion. In any shock state where the intravascular space is functionally depleted (such as the massive vasodilation seen in sepsis), the absolute physiological priority is to restore circulating volume and improve tissue perfusion. Therefore, initiating a rapid infusion of an isotonic crystalloid solution is the paramount first action to support circulation before implementing other medical orders.

Step-by-Step Solution

Analyze the vital signs and urine output.

The client has profound hypotension (mean arterial pressure is

59

mm Hg), marked tachycardia, tachypnea, and oliguria.

These findings collectively indicate a state of cardiovascular collapse and severe tissue hypoperfusion, which is characteristic of septic shock.

Interpret the arterial blood gas (ABG) values.

The low pH (

7.25

) and low HCO

_3^-

(

13

mEq/L) indicate a metabolic acidosis. The low PaCO

_2

(

31

mm Hg) indicates partial respiratory compensation.

Accurate ABG interpretation confirms that the acidosis is metabolic (likely lactic acid accumulation from shock), ruling out a primary respiratory failure.

Apply the ABCs (Airway, Breathing, Circulation) framework to prioritize interventions.

Circulatory failure is identified as the most immediate life-threatening issue. The airway is intact, and breathing is physiologically compensating.

Prioritization requires addressing the most critical physiological deficit first, which in this case is the profound lack of intravascular volume and perfusion.

Select the appropriate initial intervention for shock stabilization.

Administering isotonic crystalloid fluids is prioritized as the first-line action.

In septic shock, massive vasodilation causes relative hypovolemia. The vascular tank must be filled with fluids before utilizing vasopressors or focusing on the infectious source.

Key Concept

Prioritization of care in septic shock involves immediate fluid resuscitation to correct life-threatening hypoperfusion and metabolic acidosis before administering vasopressors or antibiotics.

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