Question 1
An adult client in the ED is febrile and lethargic with BP 84/50, HR 128, RR 26, and suspected sepsis.
Which action should the nurse take first?
- Obtain blood cultures and start rapid isotonic fluid resuscitation per sepsis protocol.
- Hang broad-spectrum antibiotics immediately and draw cultures when able.
- Wait for the provider to assess the client at the bedside before intervening.
- Document the abnormal vital signs and continue to monitor closely.
Explanation: Early sepsis care prioritizes perfusion and obtaining cultures before antibiotics when feasible; initiate isotonic fluids and draw cultures per protocol. Administering antibiotics first, waiting for the provider, or focusing on documentation delays time-critical resuscitation.