NGN case study
Postoperative Sepsis Risk
A 67-year-old client is 2 days postoperative after bowel resection. Setting: Medical-surgical unit.
Client record
Nurses' Notes
- 0800: Reports chills and increasing incisional pain.
- 0830: Incision edges approximated; drainage is cloudy with odor.
- 0900: Client states, "I feel confused and weak."
Vital Signs
- 0600: T 37.7 C, HR 94, BP 128/76, RR 18, SpO2 96% RA.
- 0900: T 38.9 C, HR 118, BP 94/58, RR 24, SpO2 93% RA.
Laboratory Results
- WBC 18,600/mm3; lactate 3.1 mmol/L.
- Creatinine increased from 0.9 to 1.4 mg/dL.
- Urine output 20 mL/hr for the last 2 hours.
Orders
- Maintain IV lactated Ringer's at 75 mL/hr.
- Morphine 2 mg IV every 4 hr PRN severe pain.
- Notify provider for systolic BP below 100 mmHg.
Questions
Question 1 of 6
Recognize cues. Which findings require immediate follow-up? Select all that apply.
Answer and rationale
- A. Blood pressure 94/58 mmHg
- B. Lactate 3.1 mmol/L
- C. Cloudy, foul-smelling wound drainage
- D. Incisional pain increasing since morning
The client has signs of infection with possible hypoperfusion. SpO2 of 96% earlier is not the urgent cue.
Low blood pressure, elevated lactate, infected drainage, and worsening pain are concerning cues.
Question 2 of 6
Analyze cues. For each finding, classify whether it supports sepsis, expected postoperative recovery, or needs more data.
Choose for each row.
| Item | Supports sepsis | Expected recovery | Needs more data |
|---|---|---|---|
| Temperature 38.9 C with chills | |||
| WBC 18,600/mm3 | |||
| Approximated incision edges | |||
| New confusion and weakness |
Answer and rationale
- Temperature 38.9 C with chills: Supports sepsis
- WBC 18,600/mm3: Supports sepsis
- Approximated incision edges: Expected recovery
- New confusion and weakness: Supports sepsis
NGN matrix items require sorting cues, not reacting to one value in isolation.
Fever, leukocytosis, and acute mental status change support sepsis; approximated wound edges alone are expected.
Question 3 of 6
Prioritize hypotheses. Complete the bow-tie by selecting the most likely condition, two actions, and two parameters to monitor.
Complete the diagram: 1 condition, the actions to take, and the parameters to monitor.
Actions to take
Condition
Parameters to monitor
Answer and rationale
- Condition: Sepsis with hypoperfusion
- Actions to take: Obtain ordered cultures before antibiotics if this does not delay care, Increase IV fluid support as prescribed and prepare for sepsis protocol
- Parameters to monitor: Urine output, Lactate and blood pressure trend
Bow-tie items test whether the candidate can connect condition, actions, and monitoring rather than pick one isolated answer.
The bow-tie centers on sepsis with hypoperfusion, urgent infection workup/fluid support, and perfusion monitoring.
Question 4 of 6
Take action. Which action should the nurse take first?
Answer and rationale
A. Notify the provider using current vital signs, lactate, urine output, and wound findings.
The provider notification threshold is met and the client shows possible sepsis with hypoperfusion.
Escalate immediately with objective data.
Question 5 of 6
Evaluate outcomes. After initial treatment, which trend best indicates improvement?
Trend after treatment (earliest → latest):
- Blood pressure: 94/58 → 102/64 → 116/70
- Heart rate: 118 → 104 → 92
- Urine output: 20 mL/hr → 32 mL/hr → 45 mL/hr
Answer and rationale
A. Improving blood pressure, heart rate, and urine output
For sepsis, improved hemodynamics and urine output are stronger early outcome markers than one isolated symptom.
Improving perfusion markers show response to treatment.
Question 6 of 6
Generate solutions. Complete the nurse's plan of care using the best drop-down choices.
Choose the option that best completes each blank.
Priority problem: . Priority action: . Evaluation finding: .
Answer and rationale
Priority problem: infection with hypoperfusion. Priority action: escalate and prepare for sepsis protocol. Evaluation finding: urine output improves to at least 30 mL/hr.
Drop-down cloze items test a connected clinical sentence: problem, action, and measurable evaluation.
Prioritize infection with hypoperfusion, escalate care, and evaluate perfusion.