When caring for a patient weighing 60 kg who has just been admitted with septic shock, which of these assessment data greatest concern to the nurse?

Arterial oxygen saturation is 90%.

Urine output 15 ml for 2 hours.

Apical pulse 110 beats/min.

BP 94/56 mm Hg.

Answer and Explanation

The Correct Answer is D

Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. Hypotension, as indicated by a low blood pressure reading, is a significant concern in septic shock. It reflects inadequate perfusion to vital organs and tissues, leading to potential organ dysfunction and damage.
While all the assessment data provided may be important and require attention, the low blood pressure (BP) reading indicates impaired systemic perfusion and can contribute to end-organ damage. The nurse should prioritize interventions aimed at improving perfusion and stabilizing the patient's blood pressure.
A. Arterial oxygen saturation is 90% in (option A) is incorrect because While an arterial oxygen saturation of 90% is below the desired range, it is not as immediately life-threatening as low blood pressure. Oxygen therapy and interventions to improve oxygenation should still be initiated, but addressing hypotension takes priority.
B. Urine output of 15 ml for 2 hours in (option B) is incorrect because Decreased urine output is a concerning sign, as it may indicate impaired renal perfusion. However, the immediate concern in septic shock is addressing the low blood pressure to improve overall perfusion, including renal perfusion.
C. Apical pulse 110 beats/min in (option C) is incorrect because: Tachycardia is a common finding in septic shock and represents the body's compensatory response to maintain cardiac output. While it requires monitoring and consideration, low blood pressure is a more significant concern.

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Correct Answer is A

Explanation

The stages of shock are commonly described as the initial, compensatory, progressive, and refractory stages. Here is an explanation of each stage and why the patient's assessment findings correspond to the progressive stage:
B. The compensatory stage in (option B) is incorrect because, In the compensatory stage, the body continues to activate compensatory mechanisms to maintain perfusion. This includes increased heart rate, peripheral vasoconstriction, and shunting of blood to vital organs. The patient's assessment findings of decreasing cardiac output, decreased peripheral perfusion, and increased capillary permeability suggest that the body's compensatory mechanisms are no longer sufficient to maintain perfusion adequately. Therefore, the patient has progressed beyond the compensatory stage.
C. The initial stage in (option C) is incorrect because, In the initial stage, there is an initial insult or injury that triggers the shock state. The body's compensatory mechanisms are activated, such as increased heart rate and vasoconstriction, to maintain blood pressure and perfusion. However, the patient's assessment findings indicate that they have progressed beyond the initial stage.
D. The refractory stage in (option D) is incorrect because The refractory stage represents a severe and irreversible state of shock where vital organs fail, and despite interventions, the patient's condition does not improve. The patient's assessment findings do not suggest the refractory stage, as there is still potential for intervention and management.

A. Oxygen saturation 92% B. Skin cool and clammy C. Blood pressure (BP) 92/56 mm Hg D. Heart rate 118 beats/minute

Correct Answer is B

Explanation

A. Oxygen saturation of 92% in (option A) is incorrect because While an oxygen saturation of 92% is suboptimal and may require intervention, it may not have the same immediate implications as low blood pressure. The healthcare provider should be informed, but addressing the blood pressure takes priority.
B. Skin cool and clammy in (option B) is correct because Cool and clammy skin is often associated with inadequate peripheral perfusion, which is a characteristic of septic shock.

C. Septic shock is characterized by systemic inflammation, vasodilation, and hypotension. Inadequate blood pressure is a significant concern in septic shock as it indicates poor tissue perfusion and compromised organ function. However, the mean arterial pressure is till acceptable.
D. Heart rate of 118 beats/minute in (option D) is incorrect because: Tachycardia is a common finding in septic shock and reflects the body's compensatory response to maintain cardiac output. While it is a significant finding, low blood pressure takes precedence in terms of urgency.

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When caring for a patient weighing 60 kg who has just been admitted with septic shock, which of these assessment data greatest concern to the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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