Clinical judgment · practice question
A 72-year-old client is admitted from a long-term care facility with a urinary tract infection. Highlight the findings in the nurse's note that require immediate follow-up.
Highlight textHard
Select the findings that apply.
Nurse's note, 1000:
Answer and explanation
Correct answer
- Temperature 38.9°C (102°F).
- Heart rate 118/min.
- Blood pressure 86/50 mm Hg.
- Alert but newly confused about the date; the facility reports the client is normally oriented.
- Last voided 6 hours ago, 100 mL of dark amber urine.
Why
Fever, tachycardia, hypotension, new confusion and low urine output in a client with a known infection point to sepsis with hypoperfusion. That's a time-critical emergency.
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