# A client with suspected infection has temperature 39.2 C, heart rate 126/min, blood pressure 84/46 mm Hg, and new confusion. Which action should the nurse expect first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397263&lang=en  
> language: en  
> subject: Illness Management  
> category: PA

## Question

A client with suspected infection has temperature 39.2 C, heart rate 126/min, blood pressure 84/46 mm Hg, and new confusion. Which action should the nurse expect first?

## Option

1. Delay treatment until a positive culture result returns.
2. Initiate the sepsis protocol, including cultures, lactate, fluids, and antibiotics as prescribed. **✔ Correct answer**
3. Provide only oral fluids and recheck vital signs in 6 hours.
4. Place the client on a low-protein diet.

**Correct answer: 2**

## Explanation

Fever, tachycardia, hypotension, and confusion suggest sepsis with hypoperfusion. Early sepsis care includes prompt recognition, cultures and lactate as ordered, fluid resuscitation, and timely antibiotics. Waiting for culture confirmation can delay lifesaving treatment.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Suspected sepsis with hypoperfusion.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Suspected sepsis with hypoperfusion, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Sepsis** — Life-threatening organ dysfunction caused by a dysregulated response to infection.
- **Lactate** — A marker that can rise when tissue perfusion is inadequate.
- **Hypoperfusion** — Insufficient blood flow to meet tissue needs.

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