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?
1Administer an antipyretic and reassess the client's level of consciousness in 30 minutes.
2Obtain a stat CT scan of the head to rule out a neurological cause for the confusion.
3Initiate the sepsis protocol, including cultures, lactate, fluids, and antibiotics as prescribed.✓ Correct answer
4Begin a norepinephrine infusion to treat the hypotension before administering intravenous fluids.
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. Option 1 is incorrect because administering an antipyretic and waiting to reassess delays definitive treatment and does not address the underlying infection or shock. Option 2 is incorrect: while new confusion may raise concern for a neurological cause, in the context of sepsis with hypotension, stabilizing hemodynamics and treating infection takes priority over CT imaging. Option 4 is incorrect: guidelines recommend initial fluid resuscitation for sepsis-induced hypoperfusion before starting vasopressors; beginning norepinephrine without adequate fluids can worsen tissue perfusion. Option 3 correctly initiates the sepsis protocol, aligning with evidence-based protocols for immediate management.
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 Practice GuideFor Suspected sepsis with hypoperfusion, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
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.