Question

A client admitted with septic shock has a BP of 70/46 mm Hg, pulse 125, respirations 30, temperature 103° F, and blood glucose 266 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

A. Administer a fluid bolus of normal saline IV at 500 mL/hr.
B. Administer acetaminophen (Tylenol) 650 mg rectally.
C. Administer an insulin drip to maintain blood glucose at 110 to 150 mg/dL.
D. Administer norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

Answer 1

The first intervention for a patient in septic shock with a significantly low blood pressure should be to administer a fluid bolus of normal saline IV at 500 mL/hr to improve blood flow and blood pressure.

Step-by-step explanation:

The client admitted with septic shock has a significantly low blood pressure and other signs of instability, such as a high pulse rate, high temperature, and altered blood glucose levels. The first intervention to implement, according to the priority of treating shock, is to administer a fluid bolus of normal saline IV at 500 mL/hr. This will help to counteract the prevailing hypotension and improve blood flow to vital organs. Other interventions may follow but stabilizing the circulatory system takes precedence to prevent further deterioration and potential organ failure.