# A client with pyelonephritis and suspected sepsis has just completed the initial 30 mL/kg IV crystalloid bolus. Blood cultures were drawn and the first dose of piperacillin-tazobactam was given 40 minutes ago; there is no rash, wheezing, or lip swelling. On reassessment: temperature 38.9°C (102°F), blood pressure 84/50 mm Hg, mean arterial pressure 62 mm Hg, heart rate 118/min, capillary refill 3 seconds, and urine output 22 mL/hr. A passive leg raise produces no change in blood pressure. Lactate is 2.8 mmol/L (initial 4.1 mmol/L). Lungs are clear. The provider has prescribed norepinephrine to keep MAP at or above 65 mm Hg if hypotension persists after fluids. 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=617434&lang=en  
> language: en  
> subject: Illness Management  
> category: PA

## Question

A client with pyelonephritis and suspected sepsis has just completed the initial 30 mL/kg IV crystalloid bolus. Blood cultures were drawn and the first dose of piperacillin-tazobactam was given 40 minutes ago; there is no rash, wheezing, or lip swelling. On reassessment: temperature 38.9°C (102°F), blood pressure 84/50 mm Hg, mean arterial pressure 62 mm Hg, heart rate 118/min, capillary refill 3 seconds, and urine output 22 mL/hr. A passive leg raise produces no change in blood pressure. Lactate is 2.8 mmol/L (initial 4.1 mmol/L). Lungs are clear. The provider has prescribed norepinephrine to keep MAP at or above 65 mm Hg if hypotension persists after fluids. 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
Sepsis with an adequate response to fluids
Hypovolemic shock needing additional crystalloid volume
Anaphylactic reaction to the antibiotic
Septic shock persisting after fluid resuscitation

Actions to take

Select 2
Give a second 30 mL/kg crystalloid bolus
Report the MAP of 62 mm Hg to the provider
Delay vasopressors until an arterial line is placed
Prepare to start the prescribed norepinephrine
Administer intramuscular epinephrine 0.3 mg

Parameters to monitor

Select 2
Central venous pressure
Serum tryptase level
Mean arterial pressure
White blood cell count
Serum lactate trend

## Explanation

Persistent MAP below 65 mm Hg with lactate still above 2 mmol/L after 30 mL/kg crystalloid, and no response to a passive leg raise, defines septic shock requiring vasopressors. The nurse reports the MAP and prepares the prescribed norepinephrine rather than giving another large bolus. MAP and the lactate trend show whether perfusion is restored.

## In-depth explanation

Quick answer
Septic shock persisting after fluid resuscitation; report the MAP of 62 mm Hg and prepare the prescribed norepinephrine; monitor mean arterial pressure and the serum lactate trend.

Why this is correct
Septic shock is sepsis with hypotension that needs vasopressors to keep MAP at or above 65 mm Hg, with lactate above 2 mmol/L despite adequate fluids. This client received the full bolus, remains at MAP 62 mm Hg, and shows no fluid responsiveness on passive leg raise, so more crystalloid is unlikely to help. Norepinephrine is first-line and can be started through a well-functioning peripheral line while an arterial line is arranged. A falling lactate and a MAP at or above 65 mm Hg indicate improving perfusion.

Easy analogy or mental picture
The pipes (vessels) have gone slack, so pouring more water in only fills the slack; norepinephrine tightens the pipes so the existing water reaches the organs.

Memory hook
"Filled but still low — squeeze, don't pour."

NCLEX decision rule
After adequate fluid resuscitation, a MAP below 65 mm Hg means vasopressors; judge the response by MAP and lactate clearance.

Why the other choices are wrong
A second full bolus is tempting for hypovolemia, but the passive leg raise shows no fluid responsiveness and repeated boluses risk fluid overload. Delaying vasopressors for an arterial line prolongs hypoperfusion. IM epinephrine treats anaphylaxis, which is unlikely without rash, wheezing, or angioedema. An adequate response is ruled out by MAP 62 mm Hg and lactate 2.8 mmol/L. CVP is no longer recommended as a resuscitation target, tryptase tracks anaphylaxis, and WBC reflects infection rather than perfusion.

References
1SCCM — Surviving Sepsis Campaign Adult GuidelinesNorepinephrine is first-line for persistent hypotension after initial fluids, targeting MAP 65 mm Hg, with lactate-guided resuscitation.

## Clinical scenario

Scenario
After a full 30 mL/kg crystalloid bolus for sepsis, MAP remains 62 mm Hg, lactate is still elevated, urine output is low, and a passive leg raise shows no fluid responsiveness.

## Key concepts

- **Mean arterial pressure (MAP)** — The average pressure driving organ perfusion; the initial septic-shock target is at least 65 mm Hg.
- **Lactate clearance** — A falling serum lactate over time, indicating improving tissue perfusion.
- **Passive leg raise** — A bedside test that transiently increases venous return to predict whether more fluid will raise cardiac output.

## Related questions

- [A client with suspected urosepsis has a temperature of 39.1 C, blood pressure 86/48 mm Hg,…](https://mymerci.kr/pages/nclex_q.php?qn_id=393666&lang=en)
- [A client with diabetic ketoacidosis is prescribed IV insulin. The potassium level is 2.9 m…](https://mymerci.kr/pages/nclex_q.php?qn_id=394074&lang=en)
- [A client with adrenal insufficiency has vomiting, severe weakness, blood pressure 78/42 mm…](https://mymerci.kr/pages/nclex_q.php?qn_id=394151&lang=en)
- [Place the actions in order for an adult with probable sepsis, a mean arterial pressure of …](https://mymerci.kr/pages/nclex_q.php?qn_id=394886&lang=en)
- [Drag each assessment trend to the heart-failure perfusion profile it best supports.](https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=en)
- [A client has a potassium level of 6.9 mEq/L and a widened QRS complex. For each finding or…](https://mymerci.kr/pages/nclex_q.php?qn_id=395582&lang=en)
- [A client with suspected infection has temperature 39.2 C, heart rate 126/min, blood pressu…](https://mymerci.kr/pages/nclex_q.php?qn_id=397263&lang=en)
- [A client develops stridor, facial swelling, and hypotension after receiving an antibiotic.…](https://mymerci.kr/pages/nclex_q.php?qn_id=397318&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617434&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617434&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617434&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617434&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617434&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._