# Stage 5 — Take action. At 0720 the nurse receives the sepsis orders. The client's BP is 82/48 mm Hg (MAP 59), HR 124/min, the client is confused, and urine output was 15 mL in the past 2 hours. One 18-gauge catheter is in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr, and the prescribed lactated Ringer's bolus is at the bedside. Pharmacy will deliver the piperacillin-tazobactam at about 0740. A second nurse will be free to assist with catheter insertion at 0730. The urologist plans ureteral stent placement after initial resuscitation. Place the actions in the order the nurse should perform them.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617245&lang=en  
> language: en  
> subject: Standard/Transmission-Based Precautions/Surgical Asepsis  
> category: SIPC

## Question

Stage 5 — Take action. At 0720 the nurse receives the sepsis orders. The client's BP is 82/48 mm Hg (MAP 59), HR 124/min, the client is confused, and urine output was 15 mL in the past 2 hours. One 18-gauge catheter is in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr, and the prescribed lactated Ringer's bolus is at the bedside. Pharmacy will deliver the piperacillin-tazobactam at about 0740. A second nurse will be free to assist with catheter insertion at 0730. The urologist plans ureteral stent placement after initial resuscitation. Place the actions in the order the nurse should perform them.

Draw two blood-culture sets by venipuncture at two separate sites

Administer the piperacillin-tazobactam as soon as it arrives on the unit

Complete the consent and transport checklist for the ureteral stent

Insert the prescribed indwelling urinary catheter and send a urine culture

Start the prescribed lactated Ringer's bolus through the forearm catheter

## Explanation

The bolus starts first because access already exists and the client is hypotensive. Blood cultures are drawn from two fresh venipuncture sites (not the infusing line) while the antibiotic is still on its way, the catheter and urine culture follow when the second nurse is available at 0730, the antibiotic is given on arrival at 0740 so every culture precedes it without delaying it, and stent preparation follows initial resuscitation and antimicrobial therapy.

## In-depth explanation

Quick answer
3, 5, 1, 2, 4: start the bolus, draw blood cultures, insert the catheter with urine culture, give the antibiotic on arrival, then complete stent preparation.

Why this is correct
The sequence is set by this client's data. Hypotension with working IV access means fluid can start within a minute, so nothing should precede it. The antibiotic is not available until 0740, so the 20-minute gap is used to obtain cultures, which improves pathogen identification without delaying therapy. Blood cultures come before the catheter because they need no second person and must be drawn by separate venipuncture rather than from the line carrying saline. The catheter is inserted with sterile technique at 0730 when help arrives, and the urine culture is also collected before the first antibiotic dose. Source control is urgent but is planned after initial resuscitation and antimicrobials have begun.

Easy analogy or mental picture
Think of a pit crew: the fuel line (fluid) goes in first because the hose is already attached, the inspection (cultures) happens while the part (antibiotic) is on its way, and the car is sent to the garage (stent) once it can safely drive.

Memory hook
Fluid when you can, cultures while you wait, antibiotics when they arrive, source control after.

NCLEX decision rule
Sequence sepsis actions by what can start now and what is waiting: never delay fluids or antibiotics for cultures, but use unavoidable waiting time to obtain cultures first.

Why the other choices are wrong
Drawing cultures before the bolus is tempting because of the rule 'cultures before antibiotics,' but that rule concerns antibiotics, not fluids, and delaying fluid in a MAP of 59 is unsafe. Inserting the catheter before blood cultures is tempting because urine is the source, but it requires the second nurse who is not free until 0730. Giving the antibiotic before any culture would be correct if it were already at the bedside, but it will not arrive until 0740. Moving stent preparation earlier is tempting because source control is essential, but the urologist has planned it after initial resuscitation.

References
1Society of Critical Care Medicine: Surviving Sepsis Campaign guidelinesObtain cultures before antimicrobials when this causes no substantial delay; give antimicrobials within 1 hour in septic shock; begin crystalloid resuscitation; achieve source control
2CDC: SepsisHospital sepsis care: rapid recognition, cultures, antibiotics, and fluid resuscitation

## Clinical scenario

Case update
Two peripheral blood-culture sets and a urine culture are prescribed while the antimicrobial is being prepared by pharmacy.

## Key concepts

- **Source control** — Procedures such as ureteral stenting that remove or drain an infected focus.
- **Blood-culture venipuncture** — Drawing culture specimens from fresh peripheral sites rather than from an infusing line to avoid dilution and contamination.
- **Time-to-antibiotic** — The interval from shock recognition to the first antimicrobial dose, which should be within 1 hour in septic shock.

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