# A nurse is performing a focused assessment on a 72-year-old client with suspected sepsis from a urinary source. Identify all findings consistent with sepsis or septic shock that require immediate provider notification. Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=368579&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A nurse is performing a focused assessment on a 72-year-old client with suspected sepsis from a urinary source. Identify all findings consistent with sepsis or septic shock that require immediate provider notification. Select all that apply. 1Heart rate 122/min, sustained tachycardia 2Mean arterial pressure 58 mm Hg 3Capillary refill 2 seconds 4Temperature 38.9 C with shaking chills 5Skin warm and dry to touch 6Respiratory rate 26/min with increased work of breathing 7Bowel sounds active in all 4 quadrants 8Serum lactate 4.1 mmol/L 9Oxygen saturation 98 percent on room air 10Hand grasps strong and equal bilaterally ## Explanation Sepsis criteria (Sepsis-3): suspected infection plus acute change in SOFA 2 or more. Septic shock: persistent hypotension requiring vasopressors plus lactate above 2 despite fluid resuscitation. qSOFA bedside: RR 22 or more, altered mental status, SBP 100 or less. Findings consistent: (1) HR 122 — sustained tachycardia, (2) MAP 58 mm Hg — under perfusion threshold of 65, (4) T 38.9 with rigors — infection signal, (6) RR 26 with increased effort — qSOFA positive, (8) lactate 4.1 — tissue hypoperfusion. Cap refill 2 s (3) is normal. Warm dry skin (5) and SpO2 98 percent (9) are reassuring not concerning. Strong hand grasps (10) is normal neuro. ## In-depth explanation Sepsis Recognition Bundle qSOFA: RR 22 or more, altered LOC, SBP 100 or less. Hour-1: lactate, blood cultures, antibiotics, fluids, vasopressors. Findings — Concerning 1. HR 122/min — sustained tachycardia from compensated shock 2. MAP 58 mm Hg — below 65 perfusion target 3. T 38.9 plus rigors — infection signal 4. RR 26 with effort — qSOFA positive 5. Lactate 4.1 — tissue hypoperfusion Findings — Reassuring - Cap refill 2 s (normal under 3) - Skin warm dry (early sepsis can show this) - SpO2 98 percent room air - Bowel sounds, hand grasps normal Action Notify provider, initiate Hour-1 bundle. NCSBN Theme PA — Medical emergency / sepsis recognition. ## Clinical scenario Scenario 72-year-old, suspected sepsis from urinary source. Findings to Sort 10 assessment findings — identify those consistent with sepsis or septic shock. Sepsis-3 + qSOFA - qSOFA positive: 2 or more of (RR 22+, altered LOC, SBP 100-) - Septic shock: vasopressor plus lactate over 2 despite fluids ## Key concepts - **Sepsis-3 / qSOFA** — Sepsis: suspected infection plus acute change in SOFA 2 or more. Septic shock: persistent hypotension on vasopressors plus lactate above 2 mmol/L despite adequate fluid resuscitation. qSOFA quick bedside screen: RR 22 or more, altered mental status, SBP 100 or less — 2 of 3 suggests sepsis with poor outcome. - **Lactate as a perfusion marker** — Serum lactate above 2 mmol/L suggests tissue hypoperfusion; above 4 mmol/L is associated with significantly higher mortality. Used in Surviving Sepsis Hour-1 bundle as both diagnostic and reperfusion target — repeat at 2 to 4 hours to assess response. Other causes of elevated lactate: shock of any type, severe exercise, metformin toxicity, propofol infusion syndrome. - **Surviving Sepsis Hour-1 bundle** — (1) Measure lactate; (2) Blood cultures before antibiotics; (3) Broad-spectrum IV antibiotics; (4) 30 mL/kg crystalloid for hypotension or lactate above 4; (5) Vasopressor (norepinephrine first-line) if MAP under 65 after fluid. 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