The nurse recognizes that a patient with sepsis is at risk to develop hypotension. Which pathophysiological process is responsible for this symptom?
Vasodilation and fluid shift out of the vascular space
Platelet aggregation and thrombus formation
Decreased blood glucose and oliguria
Hypoxemia and anaerobic metabolism
The Correct Answer is A
Choice A reason: In sepsis, inflammatory mediators cause vasodilation and increased capillary permeability, leading to fluid leaking out of the vascular space, resulting in hypotension.
Choice B reason: Platelet aggregation and thrombus formation can occur in sepsis but are more related to disseminated intravascular coagulation (DIC) rather than directly causing hypotension.
Choice C reason: Decreased blood glucose and oliguria can be consequences of sepsis but are not the primary pathophysiological processes responsible for hypotension.
Choice D reason: Hypoxemia and anaerobic metabolism may result from the effects of sepsis on the body, including hypotension, but they are not the direct cause of hypotension.
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Correct Answer is D
Explanation
Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.
Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.
Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.
Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.
Correct Answer is B
Explanation
Choice A reason: Monitoring heart rate and rhythm is important in heart failure management, but it does not directly reflect the effectiveness of enalapril and furosemide, which are primarily used to control blood pressure and reduce fluid overload, respectively.
Choice B reason: Auscultating lung fields can reveal the presence of fluid, indicating pulmonary edema, a common complication of left-sided heart failure. Checking BP is essential as enalapril is an ACE inhibitor that lowers BP, and furosemide can also affect BP through its diuretic effect.
Choice C reason: Assessing for JVD can indicate right-sided heart failure, which may develop secondary to left-sided heart failure. However, it is not the primary assessment for the effectiveness of enalapril and furosemide.
Choice D reason: Checking peripheral pulses is a general assessment and, while important, it does not specifically evaluate the effectiveness of the medications in question.
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