Sepsis And Shock: Recognition And Priorities Practice Test

A 76-year-old long-term care resident with a chronic indwelling urinary catheter is newly agitated and pulling at lines. Findings: temperature 38.6°C, heart rate 118/min, blood pressure 86/52 mm Hg, respiratory rate 22/min, oxygen saturation 97% on room air; urine is cloudy; white blood cell count 14,800/mm³ (4,500–11,000). What is the PRIORITY nursing action?

A 71-year-old client is 2 days post hip replacement and reports feeling “cold and shaky.” Assessment: temperature 39.0°C, heart rate 118/min, blood pressure 92/52 mm Hg, respiratory rate 22/min, oxygen saturation 95% on 2 L nasal cannula; incision is clean but the urinary catheter drainage is cloudy; white blood cell count 16,400/mm³ (4,500–11,000). Which intervention should be implemented IMMEDIATELY?