A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.
The nurse should identify which of the following findings as indicative of an infection?

Choice A rationale:

Obtaining a wound culture is crucial to identify the causative organism and guide appropriate antibiotic therapy. Prompt identification and treatment of the infection source can prevent further systemic complications.

Choice B rationale:

Rapidly administering 30 mL/kg of normal saline helps to restore intravascular volume, improve hemodynamic stability, and enhance tissue perfusion. This intervention is vital in the initial management of sepsis to prevent organ dysfunction.

Choice D rationale:

Obtaining blood cultures before initiating antibiotic therapy is essential to identify the causative microorganism and tailor antibiotic treatment. This step ensures accurate diagnosis and effective management of sepsis.

Choice E rationale:

Administering broad-spectrum antibiotics as soon as possible is critical in managing sepsis. Early and appropriate antibiotic therapy significantly reduces mortality and morbidity by targeting the suspected pathogens promptly.

Choice A rationale:

The Glasgow Coma Scale score has decreased from 14 to 12, indicating a decline in the client's level of consciousness. This finding requires immediate attention as it may signify worsening neurological status or an underlying condition such as metabolic disturbances, hypoxia, or intracranial pathology.

Choice C rationale:

The bicarbonate level is 13 mEq/L, which is significantly lower than the normal range of 21-28 mEq/L. This indicates metabolic acidosis, a condition where the blood is too acidic. It requires immediate intervention to prevent severe complications such as shock or organ failure.

Choice F rationale:

The client's blood pressure readings show hypotension with a supine blood pressure of 100/70 mm Hg and sitting blood pressure of 85/50 mm Hg. This suggests hemodynamic instability, which could be due to dehydration, sepsis, or other critical conditions requiring urgent treatment.

Choice G rationale:

The ECG findings indicate tachycardia with a prolonged PR interval, widened QRS complex, and peaked T waves. These are signs of hyperkalemia, a potentially life-threatening condition requiring immediate attention to prevent cardiac arrest.

Choice H rationale:

The sodium level is 152 mEq/L, which is higher than the normal range of 136-145 mEq/L, indicating hypernatremia. This electrolyte imbalance can lead to severe neurological symptoms and requires prompt correction to prevent complications such as seizures or coma.