A client arrives at the emergency department triage area displaying severe dyspnea, a temperature of 102.4°F (39.1°C), and a blood pressure of 86/48 mm Hg. The provider prescribes several immediate interventions for suspected sepsis. In what sequence should the nurse perform the following actions? Arrange the actions in the order they should be implemented, from first to last.
- 1Administer supplemental oxygen via a non-rebreather mask.
- 2Establish large-bore peripheral intravenous access.
- 3Obtain peripheral blood cultures.
- 4Infuse the prescribed intravenous broad-spectrum antibiotic.
Answer
The correct sequence is to first administer oxygen, followed by establishing intravenous access, then obtaining blood cultures, and finally infusing the broad-spectrum antibiotic.
The correct sequence adheres strictly to the Airway, Breathing, Circulation (ABC) framework and evidence-based sepsis protocols. Supporting breathing with oxygen is the absolute first step. Next, establishing circulation via intravenous access allows for subsequent treatments. Finally, drawing blood cultures must precede the administration of broad-spectrum antibiotics to ensure accurate pathogen identification.
Step-by-Step Solution
Key Concept
Prioritization using the ABC framework and the standard sequence of sepsis interventions (cultures before antibiotics).