Question

When assessing a client for early sepsis, which assessment finding would most concern the nurse?

1. pale, yellow urine
2. mean arterial pressure less than 70 mmHg
3. two-second capillary refill
4. purulent drainage from surgical site

Answer 1

The most concerning assessment finding when assessing for early sepsis is a mean arterial pressure less than 70 mmHg, which can lead to septic shock.

Step-by-step explanation:

When assessing a client for early sepsis, the most concerning assessment finding for a nurse would be mean arterial pressure (MAP) less than 70 mmHg. A MAP less than 70 mmHg indicates that the tissues and organs may not be receiving enough blood flow, which is a critical condition that can lead to septic shock. Septic shock is characterized by a significant drop in blood pressure, leading to a reduction in the delivery of oxygen and nutrients to the body's tissues. Other findings such as pale, yellow urine, two-second capillary refill, and purulent drainage from a surgical site, while potentially serious, do not alone signify the immediate life-threatening event that a low MAP represents in the context of sepsis.