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Sepsis and Septic Shock — NCLEX Cheat Sheet

Q: What are the warning signs of Sepsis and Septic Shock a nurse must report?

MAP < 65 mmHg, lactate rising, or urine output < 30 mL/hr — escalate immediately.

Q: What lab values are associated with Sepsis and Septic Shock?

Lactate elevated (> 2 mmol/L). WBC high or low; positive cultures.

Infection → organ failure

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👤 By the CinnaRN Clinical Content Team 🕐 Updated 2026-08-23 🏷️ Physiological Adaptation 🔖 Free to read, print, and share

Also known as: sepsis · septic shock · systemic infection · bloodstream infection

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Use this quick-reference guide to spot, treat, and prevent Sepsis and Septic Shock on the NCLEX. Keep it handy during review and on exam day!

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📒 The 1-minute cheat sheet

🩺 Signs

Early: warm, flushed, ↑ HR
Late: cold, clammy, ↓ BP
↑ lactate, fever, ↑ WBC

✅ Do

Cultures BEFORE antibiotics
Broad abx within 1 hour
30 mL/kg IV fluid bolus

🩺 Watch

Vasopressors if fluid fails
Norepi = first-line presser
Monitor MAP ≥ 65 mmHg

🚩 Report

↓ UO, ↓ LOC = hypoperfusion
Lactate not clearing = worsening

📚 Sepsis and Septic Shock — full study notes

The cheat sheet above is your quick recall card. These notes go deeper — what it is, what to do first, what must be reported, and what to teach.

Sepsis is a life-threatening organ dysfunction from a dysregulated response to infection; septic shock is sepsis with persistent hypotension despite fluids. Early recognition and the Hour-1 bundle (cultures, broad-spectrum antibiotics, fluids, lactate) save lives.

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Key points

Understand these first

Early/warm phase: fever, tachycardia, tachypnea, warm flushed skin, bounding pulses
Late/cold phase: hypotension, cool clammy skin, weak pulses, decreased urine output
Elevated lactate reflects tissue hypoperfusion
Altered mental status and decreasing urine output are early warnings

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Nursing priorities

What to do, in order

Obtain blood cultures BEFORE starting antibiotics
Give broad-spectrum antibiotics within the first hour
Rapid IV crystalloid fluid resuscitation (30 mL/kg) for hypotension or high lactate
Measure lactate; add vasopressors (norepinephrine) if hypotension persists after fluids

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Red flags — report now

Escalate immediately

MAP < 65 mmHg, lactate rising, or urine output < 30 mL/hr — escalate immediately

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Labs & values

Numbers to know

Lactate elevated (> 2 mmol/L)
WBC high or low; positive cultures

❓ Sepsis and Septic Shock: NCLEX FAQs

What are the priority nursing interventions for Sepsis and Septic Shock?

Obtain blood cultures BEFORE starting antibiotics. Give broad-spectrum antibiotics within the first hour. Rapid IV crystalloid fluid resuscitation (30 mL/kg) for hypotension or high lactate. Measure lactate; add vasopressors (norepinephrine) if hypotension persists after fluids.

What are the warning signs of Sepsis and Septic Shock a nurse must report?

MAP < 65 mmHg, lactate rising, or urine output < 30 mL/hr — escalate immediately.

What do I need to know about Sepsis and Septic Shock for the NCLEX?

Early/warm phase: fever, tachycardia, tachypnea, warm flushed skin, bounding pulses. Late/cold phase: hypotension, cool clammy skin, weak pulses, decreased urine output. Elevated lactate reflects tissue hypoperfusion. Altered mental status and decreasing urine output are early warnings.

What lab values are associated with Sepsis and Septic Shock?

Lactate elevated (> 2 mmol/L). WBC high or low; positive cultures.

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