An emergency department nurse evaluates an older adult client brought in from a long-term care facility with altered mental status and a new-onset productive cough. Initial assessment reveals a blood pressure of 86/48 mm Hg, an apical pulse of 124 beats/min, and a respiratory rate of 26 breaths/min. The client's skin is warm and flushed. Serum laboratory results indicate a white blood cell count of 19,000/mm³ and a serum lactate level of 4.5 mmol/L. Which of the following priority actions should the nurse anticipate incorporating into the immediate plan of care? (Select all that apply)
- Obtain blood cultures from two different peripheral sites.Answer
- Administer a rapid intravenous infusion of 0.9% sodium chloride.Answer
- Administer prescribed broad-spectrum intravenous antibiotics.Answer
- DInitiate a continuous norepinephrine infusion prior to fluid therapy.
- EAdminister a prescribed loop diuretic to enhance renal perfusion.
- FPosition the client in high Fowler's to maximize cardiac output.
Answer
The correct interventions are to obtain blood cultures, administer a rapid infusion of 0.9% sodium chloride, and administer broad-spectrum intravenous antibiotics.
The client is experiencing septic shock, evidenced by an elevated lactate level, leukocytosis, and significant hemodynamic instability (hypotension, tachycardia). The priority is to restore tissue perfusion and treat the underlying infection. Evidence-based protocols require obtaining blood cultures before starting antimicrobials, followed immediately by administering broad-spectrum antibiotics and a rapid isotonic fluid bolus (e.g., 0.9% sodium chloride) to expand intravascular volume and improve cellular oxygenation.
Step-by-Step Solution
Key Concept
Management of Septic Shock and Systemic Inflammatory Response Syndrome (SIRS)