# A 68-year-old client is admitted to the emergency department with suspected sepsis from a urinary tract source. Vital signs: temperature 39.2°C, heart rate 122/min, respiratory rate 26/min, blood pressure 88/52 mm Hg, SpO2 94% on room air. Which interventions should the nurse anticipate initiating immediately as part of evidence-based sepsis management? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A 68-year-old client is admitted to the emergency department with suspected sepsis from a urinary tract source. Vital signs: temperature 39.2°C, heart rate 122/min, respiratory rate 26/min, blood pressure 88/52 mm Hg, SpO2 94% on room air. Which interventions should the nurse anticipate initiating immediately as part of evidence-based sepsis management? Select all that apply. 1 Withhold intravenous fluids until the next provider round to avoid volume overload 2 Draw a serum lactate level on arrival 3 Obtain two sets of blood cultures before starting antibiotics, if doing so does not delay antibiotic administration 4 Begin rapid intravenous crystalloid infusion at 30 mL/kg for hypotension or a lactate level of 4 mmol/L or higher 5 Limit urine output measurement to once per shift to reduce invasive monitoring 6 Administer broad-spectrum intravenous antibiotics within 1 hour of recognition ## Explanation Evidence-based immediate sepsis management includes measuring lactate (Choice 2), obtaining blood cultures before antibiotics if this does not substantially delay antimicrobial therapy (Choice 3), administering broad-spectrum IV antimicrobials immediately and ideally within 1 hour for possible septic shock or a high likelihood of sepsis (Choice 6), and beginning rapid 30 mL/kg crystalloid resuscitation for hypotension or lactate ≥ 4 mmol/L (Choice 4). Current Surviving Sepsis Campaign guidance recommends delivering at least 30 mL/kg within the first 3 hours for sepsis-induced hypoperfusion or septic shock while treatment and resuscitation begin immediately. Withholding fluids until the next provider round (Choice 1) and limiting urine-output measurement to once per shift (Choice 5) are unsafe in this hypotensive client. ## In-depth explanation Sepsis 1-Hour Bundle "Lactate · Cultures · Antibiotics · Fluids · Pressors" — completed within 60 minutes of recognition. Order of Action 1. Lactate + cultures drawn first 2. Broad-spectrum antibiotics within 1 hour — every hour delay = ↑ mortality 3. 30 mL/kg crystalloid rapid bolus if hypotensive or lactate ≥ 4 4. Vasopressors during/after fluids to keep MAP ≥ 65 mm Hg Memory Tip "L · C · A · F · P" → Lactate, Cultures, Antibiotics, Fluids, Pressors. Caution Cultures should not delay antibiotics >45 min. Hourly urine output is required to track end-organ perfusion. ## Clinical scenario Scenario 68 y.o. client, suspected urosepsis. T 39.2°C · HR 122 · RR 26 · BP 88/52 · SpO2 94% RA · WBC 18,500 · lactate pending. Initial Sepsis Recognition SIRS + suspected infection + organ dysfunction (hypotension) → activate sepsis bundle now. Within 1 Hour - 2 large-bore IV access - Lactate + 2 sets blood cultures - Broad-spectrum IV antibiotic - 30 mL/kg LR or NS bolus - Reassess MAP, lactate, mentation Red Flag Lactate ≥ 4 mmol/L OR MAP < 65 after fluids → vasopressors and ICU transfer. ## Key concepts - **Surviving Sepsis Campaign 1-hour bundle** — Evidence-based sepsis care set: measure lactate, obtain blood cultures, administer broad-spectrum antibiotics, begin 30 mL/kg crystalloid for hypotension or lactate ≥ 4, apply vasopressors to maintain MAP ≥ 65. Each hour of antibiotic delay increases mortality. - **Lactate as a perfusion marker** — Serum lactate ≥ 2 mmol/L suggests tissue hypoperfusion. ≥ 4 mmol/L meets the threshold for aggressive 30 mL/kg crystalloid resuscitation. Trend lactate q2-4h to gauge response. - **Mean arterial pressure (MAP) goal** — In septic shock, target MAP ≥ 65 mm Hg via fluids first then norepinephrine as first-line vasopressor. MAP = (SBP + 2×DBP) / 3. 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