# Stage 5 — Take action. The sepsis huddle is active and team members are preparing medications and fluids. Place this nurse's five bedside actions in the best priority sequence. Do not interpret the order as permission to delay parallel team care.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372456&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

Stage 5 — Take action. The sepsis huddle is active and team members are preparing medications and fluids. Place this nurse's five bedside actions in the best priority sequence. Do not interpret the order as permission to delay parallel team care.

Administer the prescribed empiric IV antimicrobials immediately after cultures, without waiting for final source confirmation

Reassess MAP, capillary refill, lung sounds, mentation, urine output, and dynamic fluid responsiveness during resuscitation

Obtain ordered blood cultures and lactate promptly; culture urine from a freshly replaced catheter when it remains indicated, or obtain an appropriate voided specimen if the catheter is removed

Begin continuous monitoring and prescribed balanced crystalloid while performing an immediate ABC, perfusion, and point-of-care glucose assessment

Start prescribed norepinephrine through an appropriate monitored peripheral IV if hypotension persists while fluid resuscitation continues

## Explanation

Best priority sequence
1) Begin monitoring, immediate ABC/perfusion assessment, point-of-care glucose, and prescribed balanced crystalloid. 2) Obtain blood cultures and lactate promptly and collect the urine specimen correctly when feasible. 3) Administer empiric antimicrobials immediately after cultures without waiting for final confirmation. 4) Reassess perfusion and fluid responsiveness throughout treatment. 5) Start norepinephrine promptly if hypotension persists while fluids continue. These actions overlap across the team; cultures should not delay antimicrobials, and unstable shock may require vasopressor and fluid administration concurrently.

## In-depth explanation

Step 1 — Start stabilization and monitoring
Immediate ABC/perfusion assessment, point-of-care glucose, continuous monitoring, and the prescribed balanced crystalloid begin first. Point-of-care glucose addresses a rapidly reversible cause of altered mentation while sepsis care proceeds.

Step 2 — Preserve diagnostic yield without creating delay
Collect blood cultures and lactate promptly. Manage the long-term catheter and urine specimen aseptically. Then administer empiric antimicrobials without waiting for final culture or imaging results.

Step 3 — Reassess and support pressure
Use repeated perfusion and fluid-responsiveness assessment rather than automatic repeated boluses. If hypotension persists, start norepinephrine promptly through an appropriate monitored peripheral IV while fluids continue; central access is not a prerequisite for initial support.

Key concept
The answer is the best priority sequence for one nurse's task list, not a claim that emergency team actions must wait for one another.

## Clinical scenario

Scenario (Stage 5 — Take action)
The multidisciplinary sepsis response is active. Sequence this nurse's immediate bedside responsibilities while recognizing that the larger team works in parallel.

Background
NCJMM Stage 5 — Prioritize dependent actions without converting simultaneous emergency care into an artificial serial checklist.

## Key concepts

- **Parallel sepsis care** — Monitoring, cultures, antimicrobial preparation, fluid resuscitation, source evaluation, and vasopressor readiness are coordinated across the team. Priority ordering should not create avoidable delays.
- **Dynamic fluid-responsiveness assessment** — Response to passive leg raise or a fluid bolus using stroke volume, pulse pressure, or related measures helps determine whether additional fluid is likely to improve perfusion.
- **Norepinephrine in septic shock** — Norepinephrine is the first-line vasopressor. Start promptly for persistent hypotension and titrate to the prescribed MAP range; monitored peripheral administration may avoid central-line delay.

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