A nurse is providing care to a group of patients with chronic illnesses.

Who among the following patients should the nurse identify as being at the highest risk for sepsis?

Essential

1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.

Choice A rationale

Polycystic ovarian syndrome is a hormonal disorder common among women of reproductive age. While it can lead to several complications, it does not significantly increase the risk of sepsis.

Choice B rationale

Cancer and certain treatments for cancer can weaken the immune system, increasing the risk of infections that could lead to sepsis.

Choice C rationale

Kallmann’s syndrome is a genetic condition that affects the production of a hormone involved in sexual development. It does not significantly increase the risk of sepsis.

Choice D rationale

Addison’s disease affects the adrenal glands and can disrupt the balance of hormones in the body, but it does not significantly increase the risk of sepsis.