# A nurse is caring for an adult client in the emergency department who is suspected to have sepsis. The client is hypotensive (BP 84/56) with a lactate of 4.2 mmol/L. Which interventions are part of the Surviving Sepsis 1-hour bundle that should be implemented? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A nurse is caring for an adult client in the emergency department who is suspected to have sepsis. The client is hypotensive (BP 84/56) with a lactate of 4.2 mmol/L. Which interventions are part of the Surviving Sepsis 1-hour bundle that should be implemented? Select all that apply.

1

Begin broad-spectrum antibiotics within 1 hour of recognition

2

Administer 30 mL/kg balanced crystalloid IV bolus for hypotension or lactate ≥4

3

Wait for the final blood culture results before starting antibiotics

4

Withhold all IV fluids until vasopressors are titrated to a MAP of 65

5

Obtain blood cultures from two sites before antibiotics are started

## Explanation

The Surviving Sepsis 1-hour bundle requires measuring lactate, obtaining blood cultures before antibiotics, starting broad-spectrum antibiotics within 1 hour, and giving 30 mL/kg crystalloid for hypotension or lactate of 4 or higher. Vasopressors are added if MAP remains below 65 after fluid resuscitation, not in place of fluids. Antibiotics must not be delayed waiting for culture results.

## In-depth explanation

Clinical Judgment
Surviving Sepsis 1-hour bundle (2021): measure lactate, blood cultures before antibiotics, broad-spectrum antibiotics within 1 hour, 30 mL/kg crystalloid for hypotension or lactate ≥4, vasopressors if MAP remains <65 after fluids. Time-sensitive — every hour delay raises mortality.

Memory Tip
Sepsis 1-hour: Lactate-Cultures-Antibiotics-Fluids-Pressors

KR vs US
The Surviving Sepsis Campaign is a global initiative endorsed in the US, EU, Korea, and most countries. Korean tertiary centers run sepsis bundle dashboards similar to those in the US. Both jurisdictions track door-to-antibiotic time as a quality metric.

## Clinical scenario

Clinical Practice Guide
Surviving Sepsis Campaign 2021 1-hour bundle:
- Measure lactate; remeasure if initial >2
- Obtain blood cultures before antibiotics (do not delay antibiotics >45 min)
- Administer broad-spectrum antibiotics within 1 hour
- Begin 30 mL/kg balanced crystalloid for hypotension or lactate ≥4 mmol/L
- Apply vasopressors (norepinephrine first line) if hypotension persists during or after resuscitation, target MAP ≥65

Diagnostic criteria (Sepsis-3):
- qSOFA ≥2: RR ≥22, altered mental status, SBP ≤100
- Septic shock: persistent hypotension requiring vasopressors AND lactate >2 despite fluids

Caution
Avoid hydroxyethyl starch (HES) and synthetic colloids in sepsis — increase mortality and AKI risk. Balanced crystalloids (lactated Ringer or PlasmaLyte) preferred over normal saline for large-volume resuscitation.

## Key concepts

- **Surviving Sepsis Campaign** — International multidisciplinary initiative since 2002 to reduce sepsis mortality. Publishes evidence-based guidelines updated every 4 years. The 1-hour bundle is the core nursing-led intervention.
- **qSOFA score** — Quick Sepsis-related Organ Failure Assessment. Bedside tool with 3 criteria: respiratory rate ≥22, altered mental status, SBP ≤100 mmHg. Score ≥2 suggests sepsis and need for further evaluation. Used outside the ICU; full SOFA used in critical care.
- **Septic shock** — Subset of sepsis with persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg AND serum lactate >2 mmol/L despite adequate fluid resuscitation. Mortality 40-50%. Requires ICU-level care.

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