# Six hours into sepsis bundle, the nurse reassesses fluid status and tissue perfusion. Which actions and findings indicate appropriate post-bundle reassessment? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=en  
> language: en  
> subject: Reduction of Risk Potential  
> category: ROR

## Question

Six hours into sepsis bundle, the nurse reassesses fluid status and tissue perfusion. Which actions and findings indicate appropriate post-bundle reassessment? Select all that apply.

1

Reassess fluid responsiveness with passive leg raise or stroke volume variation

2

Document lactate trend (clearance percent calculated)

3

Monitor mottling and capillary refill with MAP and urine output

4

Re-evaluate antimicrobial coverage based on culture results and source control

5

Routinely give an additional 30 mL/kg fluid bolus regardless of volume status

## Explanation

Hour-6 sepsis reassessment: trend lactate (clearance over 10-20 percent suggests adequate resuscitation), reassess fluid responsiveness with dynamic methods (passive leg raise raises preload transiently, stroke volume variation on arterial line, IVC ultrasound) — STATIC measures like CVP perform poorly. Re-evaluate antibiotics based on culture results and consider source control (drainage, debridement). Continue tissue-perfusion monitoring (mottling, capillary refill, MAP, urine). ROUTINE additional 30 mL/kg bolus is INCORRECT — fluid administration must be guided by responsiveness; over-resuscitation worsens outcomes.

## In-depth explanation

Conservative fluid strategy after initial 30 mL/kg if needed. Recent trials (CLOVERS, CLASSIC) support de-escalation toward maintenance once perfusion targets met.

## Clinical scenario

Hour 6. MAP 64 on norepinephrine, lactate dropped 4.2 to 2.8, urine 0.4 mL/kg/hr.

## Key concepts

- **passive leg raise** — Bedside test of fluid responsiveness — leg elevation transiently increases preload.
- **lactate clearance** — Percent decrease over 2-6 hours; over 10-20 percent suggests adequate resuscitation.
- **source control** — Drainage, debridement, or device removal eliminating septic source.

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