# Stage 3 — Prioritize hypotheses. The 58-year-old client with type 2 diabetes and recurrent kidney stones has had 2 days of fever, right flank pain, dysuria, and vomiting. Temperature 39.4 C, HR 124/min, RR 28/min, BP 82/48 mm Hg (MAP 59), SpO2 94% on room air; lungs are clear. The skin is warm, the knees are mottled, and capillary refill is 4 seconds. Urine output was 15 mL in 2 hours, and the client cannot name the month. Capillary glucose 186 mg/dL, lactate 4.6 mmol/L, creatinine 2.0 mg/dL (0.9 mg/dL last year). Urinalysis shows nitrites, bacteria, and pyuria; CT shows hydronephrosis above an 8-mm right ureteral stone. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617350&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

Stage 3 — Prioritize hypotheses. The 58-year-old client with type 2 diabetes and recurrent kidney stones has had 2 days of fever, right flank pain, dysuria, and vomiting. Temperature 39.4 C, HR 124/min, RR 28/min, BP 82/48 mm Hg (MAP 59), SpO2 94% on room air; lungs are clear. The skin is warm, the knees are mottled, and capillary refill is 4 seconds. Urine output was 15 mL in 2 hours, and the client cannot name the month. Capillary glucose 186 mg/dL, lactate 4.6 mmol/L, creatinine 2.0 mg/dL (0.9 mg/dL last year). Urinalysis shows nitrites, bacteria, and pyuria; CT shows hydronephrosis above an 8-mm right ureteral stone. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Hypovolemic shock from vomiting
Uncomplicated acute pyelonephritis
Septic shock from an obstructed kidney
Obstructing ureteral stone with renal colic

Actions to take

Select 2
Start dopamine as the first vasopressor
Give IV furosemide to increase urine output
Infuse the balanced crystalloid bolus
Give the prescribed broad-spectrum antibiotic
Give prescribed tamsulosin to help pass the stone

Parameters to monitor

Select 2
Urine specific gravity
Capillary blood glucose
Serum lactate
Stone passage on urine straining
Mean arterial pressure

## Explanation

Fever with a urinary source, an obstructing stone, MAP 59, lactate 4.6 mmol/L, mottling, oliguria, and confusion is septic shock from an obstructed infected kidney. A balanced crystalloid bolus and prompt broad-spectrum antibiotics start treatment while urgent decompression is arranged. MAP and lactate show whether perfusion is being restored.

## In-depth explanation

Quick answer
Septic shock from an obstructed urinary source. Take action: balanced crystalloid bolus and broad-spectrum IV antibiotic. Monitor: serum lactate and mean arterial pressure.

Why this is correct
The infected urine is trapped above the stone, so bacteria and toxins pour into the bloodstream. Hypotension with lactate above 4 mmol/L, mottled skin, confusion, and oliguria show organ hypoperfusion. Surviving Sepsis guidance calls for rapid crystalloid resuscitation, antibiotics within 1 hour after cultures, vasopressors (norepinephrine first) if MAP stays below 65, and urgent source control by stent or nephrostomy. MAP and lactate clearance are the targets that show resuscitation is working.

Easy analogy or mental picture
A clogged, infected drain is flooding the house with sewage (bacteria). Refill the water tank (fluids), treat the sewage (antibiotics), and call the plumber to unclog the drain; the pressure gauge and the smoke alarm (lactate) tell you whether it is working.

Memory hook
FEVER + STONE + SHOCK = FLUIDS, DRUGS, DRAIN; watch MAP and LACTATE.

NCLEX decision rule
When infection causes hypotension and a lactate above 4, treat as septic shock: resuscitate and give antibiotics first, then control the source; judge success by perfusion targets.

Why the other choices are wrong
Vomiting contributes volume loss but does not explain fever, bacteriuria, or warm skin with mottling; uncomplicated pyelonephritis lacks shock; renal colic alone lacks infection and organ dysfunction. Dopamine is an outdated first-line vasopressor associated with more dysrhythmias than norepinephrine. Furosemide worsens hypovolemia and does not treat hypoperfusion-related oliguria. Medical expulsive therapy is inappropriate with an infected obstructed kidney, which needs decompression. Specific gravity is a nonspecific volume marker, glucose tracks diabetes control, and urine straining tracks stone passage rather than shock response.

References
1Surviving Sepsis Campaign International Guidelines for Adults 2026Fluid resuscitation, early antimicrobials, norepinephrine as first vasopressor, source control, and MAP and lactate targets

## Clinical scenario

Case update
The urinary source, shock findings, kidney injury, and obstructing stone are now confirmed.

## Key concepts

- **Septic shock** — Sepsis with vasopressor need to keep MAP at or above 65 mm Hg and lactate above 2 mmol/L despite fluids.
- **Source control** — Removing or draining the infection focus, such as stenting an obstructed infected kidney.
- **Lactate clearance** — A falling lactate level after resuscitation, used as a marker of improving tissue perfusion.

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