A client with suspected infection has temperature 39.2 C, he… | MyMerci
Illness ManagementPA
Question
A client with suspected infection has temperature 39.2 C, heart rate 126/min, blood pressure 84/46 mm Hg, and new confusion. Which action should the nurse expect first?
1Delay treatment until a positive culture result returns.
2Initiate the sepsis protocol, including cultures, lactate, fluids, and antibiotics as prescribed.✓ Correct answer
3Provide only oral fluids and recheck vital signs in 6 hours.
4Place the client on a low-protein diet.
Explanation
Fever, tachycardia, hypotension, and confusion suggest sepsis with hypoperfusion. Early sepsis care includes prompt recognition, cultures and lactate as ordered, fluid resuscitation, and timely antibiotics. Waiting for culture confirmation can delay lifesaving treatment.
In-depth explanation
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Suspected sepsis with hypoperfusion.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For Suspected sepsis with hypoperfusion, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
Sepsis — Life-threatening organ dysfunction caused by a dysregulated response to infection.
Lactate — A marker that can rise when tissue perfusion is inadequate.
Hypoperfusion — Insufficient blood flow to meet tissue needs.