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

Answer and Explanation

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 A

Explanation

Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.

Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.

Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.

Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.

A. Neutropenia B. Hyperglycemia C. Polyuria D. Muscle cramps

Correct Answer is A

Explanation

Choice A reason: Neutropenia, a decrease in neutrophils, is a known side effect of propylthiouracil (PTU) due to its impact on bone marrow and white blood cell production.

Choice B reason: Hyperglycemia is not a typical side effect of PTU; it is more commonly associated with medications affecting blood sugar levels.

Choice C reason: Polyuria, or excessive urination, is not a common side effect of PTU and is more often related to conditions affecting kidney function or blood glucose levels.

Choice D reason: Muscle cramps are not a direct side effect of PTU; they can be associated with various conditions, including electrolyte imbalances.

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The nurse recognizes that a patient with sepsis is at risk to develop hypotension. Which pathophysiological process is responsible for this symptom?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

The nurse is reviewing data of a client receiving propylthiouracil (PTU). Which information indicates to the nurse that the client may be experiencing a side effect of this medication?

Correct Answer is A

Explanation

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