# A 78-year-old client was admitted 3 hours ago with pyelonephritis. Blood cultures were drawn and the first dose of IV ceftriaxone was given at 0900, and a 30 mL/kg crystalloid bolus was completed at 1130. At 1200 the client is newly confused with mottled knees. Temperature is 39.4°C, heart rate 128/min, respiratory rate 32/min, and blood pressure 82/46 mm Hg with a mean arterial pressure of 58 mm Hg. Lactate is 4.2 mmol/L, and urine output was 15 mL in the past hour. Lung sounds are clear, jugular veins are flat, and there is no chest pain. 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=617361&lang=en  
> language: en  
> subject: Changes in Vital Signs  
> category: ROR

## Question

A 78-year-old client was admitted 3 hours ago with pyelonephritis. Blood cultures were drawn and the first dose of IV ceftriaxone was given at 0900, and a 30 mL/kg crystalloid bolus was completed at 1130. At 1200 the client is newly confused with mottled knees. Temperature is 39.4°C, heart rate 128/min, respiratory rate 32/min, and blood pressure 82/46 mm Hg with a mean arterial pressure of 58 mm Hg. Lactate is 4.2 mmol/L, and urine output was 15 mL in the past hour. Lung sounds are clear, jugular veins are flat, and there is no chest pain. 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
Septic shock
Hypovolemic shock
Sepsis without shock
Cardiogenic shock

Actions to take

Select 2
Give a second 30 mL/kg crystalloid bolus over 30 minutes
Start prescribed norepinephrine via a peripheral IV
Hold norepinephrine until a central line is placed
Administer the prescribed IV hydrocortisone dose
Activate the rapid response team

Parameters to monitor

Select 2
Mean arterial pressure
Central venous pressure
Serum troponin level
Serum lactate level
Temperature

## Explanation

Persistent hypotension with MAP below 65 mm Hg and lactate above 2 mmol/L after adequate fluid resuscitation in a client with infection defines septic shock. The nurse escalates care and starts the prescribed norepinephrine, which may begin through a peripheral IV rather than being delayed for central access. MAP and lactate are the parameters that show response.

## In-depth explanation

Quick answer
Septic shock; activate the rapid response team and start prescribed norepinephrine peripherally; monitor MAP and serum lactate.

Why this is correct
The client has a known infection, has already received 30 mL/kg of crystalloid, and still has a MAP of 58 mm Hg with lactate 4.2 mmol/L and signs of hypoperfusion (confusion, mottling, oliguria). That meets the definition of septic shock. The Surviving Sepsis Campaign recommends norepinephrine to a MAP target of 65 mm Hg and suggests starting it peripherally rather than delaying for a central line. MAP shows the vasopressor effect and lactate clearance shows restored perfusion.

Easy analogy or mental picture
The pipes (vessels) have gone slack. Pouring in more water (fluid) is not enough once the pressure will not hold; you need to tighten the pipes (vasopressor).

Memory hook
Fluids given, MAP still under 65 = Pressor. "65 and lactate" are the two numbers to chase.

NCLEX decision rule
If hypotension persists after the initial fluid bolus in suspected sepsis, escalate and start a vasopressor without waiting for central venous access; reassess MAP and lactate.

Why the other choices are wrong
Sepsis without shock is excluded because hypotension persists after fluids and lactate is above 2 mmol/L. Hypovolemic shock is tempting in an older adult, but the full bolus is complete and fever with a urinary source points to distributive shock, so a second automatic bolus delays the vasopressor. Cardiogenic shock would show crackles, distended neck veins, or chest pain; troponin tracks that differential. Holding norepinephrine for a central line is outdated practice. Hydrocortisone is added later when vasopressor needs remain high. CVP is no longer a recommended resuscitation target, and temperature does not measure perfusion.

References
1Surviving Sepsis Campaign Adult GuidelinesNorepinephrine for MAP 65 mm Hg, peripheral start rather than delay, lactate-guided resuscitation
2CDC — Clinical care of sepsisEarly recognition and escalation of sepsis with hypoperfusion

## Clinical scenario

Scenario
An older adult with pyelonephritis remains hypotensive with a MAP of 58 mm Hg, lactate 4.2 mmol/L, confusion, mottling, and oliguria after a completed 30 mL/kg crystalloid bolus.

## Key concepts

- **Septic shock** — Sepsis with vasopressor need to keep MAP at least 65 mm Hg and lactate above 2 mmol/L despite adequate fluids.
- **Mean arterial pressure** — Average arterial pressure during one cardiac cycle; the target in septic shock is 65 mm Hg.
- **Lactate clearance** — A falling lactate level that indicates improving tissue perfusion.

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