Early sepsis often shows fever or hypothermia, tachycardia, tachypnea, and new altered mental status (confusion is an early subtle clue, especially in older adults).
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client with septic shock is being resuscitated. After adequate fluid resuscitation fails to maintain perfusion, which vasopressor is the first-line agent of choice?
Answer: A. Norepinephrine is the recommended first-line vasopressor in septic shock when fluids alone do not restore mean arterial pressure. It provides potent vasoconstriction with modest inotropy and is preferred over dopamine, which carries a higher risk of arrhythmias.
Question 2 of 5
The nurse is assessing a client in the early (warm) phase of septic shock. Which assessment finding would the nurse expect?
Answer: A. In early septic shock, massive vasodilation produces warm, flushed skin and bounding pulses despite hypotension, with tachycardia and tachypnea. Cold, clammy skin and weak thready pulses are features of late septic shock or other hypovolemic/cardiogenic shock states. Bradycardia is not expected.
Question 3 of 5
A client with sepsis has a serum lactate of 5.0 mmol/L. What does this elevated result indicate?
Answer: A. An elevated lactate (normal less than 2 mmol/L) reflects tissue hypoperfusion and anaerobic metabolism. In sepsis, a rising lactate signals worsening shock and the need for aggressive resuscitation.
Question 4 of 5
A nurse caring for a client in distributive shock from sepsis reviews the lactate level. Which result indicates worsening tissue perfusion?
Answer: A. An elevated and rising serum lactate (for example, greater than 4 mmol/L) reflects anaerobic metabolism from inadequate tissue oxygen delivery and signals worsening perfusion in shock. Lactate clearance is used to gauge response to resuscitation; a normal lactate near 1 mmol/L would be reassuring.
Question 5 of 5
A nurse is monitoring a client at risk for DIC after septic shock. Which early sign should prompt the nurse to notify the provider?
Answer: A. DIC begins with abnormal clotting that consumes platelets and factors, then progresses to bleeding. Early subtle signs include oozing from IV sites and puncture sites, petechiae, and unexpected bruising. Recognizing these early bleeding signs allows prompt intervention before life-threatening hemorrhage. Increased urine output and improved color are not warning signs of DIC.
Keep the streak going with more questions like these, each with a full rationale.
What is sepsis and septic shock?
Early recognition and rapid treatment dramatically improve survival, so sepsis is a high-priority NCLEX safety topic. It can arise from any infection source, including lungs (pneumonia), urinary tract, abdomen, wounds, and IV lines. Untreated, it progresses to septic shock and multi-organ failure.
Key points to remember
- Early sepsis often shows fever or hypothermia, tachycardia, tachypnea, and new altered mental status (confusion is an early subtle clue, especially in older adults).
- Hypotension, warm flushed skin early then cool clammy skin, and a rising lactate reflect worsening perfusion.
- Decreasing urine output signals reduced organ perfusion and kidney involvement.
- A qSOFA of altered mentation, respiratory rate 22 or higher, and systolic BP 100 or lower flags high risk.
- Septic shock is sepsis with persistent hypotension requiring vasopressors and an elevated lactate despite fluids.
- Older adults and immunocompromised patients may present atypically with confusion or hypothermia rather than fever.
- The Hour-1 bundle: measure lactate, draw blood cultures before antibiotics, give broad-spectrum antibiotics, start 30 mL/kg of crystalloid for hypotension or a lactate of 4 mmol/L or more, and add vasopressors to keep the MAP at 65 mmHg or above.
Signs & symptoms
- Early: warm, flushed, ↑ HR
- Late: cold, clammy, ↓ BP
- ↑ lactate, fever, ↑ WBC
Nursing priorities
- Recognize early warning signs and obtain blood cultures BEFORE starting antibiotics.
- Administer broad-spectrum antibiotics rapidly (within the first hour) as ordered.
- Give rapid IV isotonic fluid boluses (commonly 30 mL/kg) for hypotension and measure serum lactate.
- Monitor vital signs, mental status, urine output, and oxygenation closely and reassess perfusion.
- Prepare for vasopressors (such as norepinephrine) if hypotension persists after fluids and escalate to higher care.
Labs & values
Patient teaching
- Seek care immediately for signs of infection plus fever, fast heart rate, confusion, or feeling extremely unwell.
- Complete prescribed antibiotics fully and follow up to ensure the infection is resolving.
- Practice good hand hygiene and wound care and keep vaccinations up to date to prevent infections that lead to sepsis.
Red flags: report now
- Persistent hypotension after adequate fluids indicates septic shock and requires immediate vasopressor support.
- Rising lactate, falling urine output, or new confusion signals worsening perfusion and must be escalated now.
- Do not delay antibiotics; every hour of delay increases mortality.
- Mottled, cool, clammy skin with weak pulses indicates decompensation requiring rapid intervention.
- A MAP below 65 mmHg or urine output below 30 mL/hr despite fluids — escalate immediately.
References
Clinical references for this topic
