NCLEX-RNPhysiological AdaptationMedium
A client with pneumonia has a temperature of 38.6°C (101.5°F), respiratory rate of 24/min, white blood cell count of 14,000/mm3, productive cough, and new-onset confusion with a blood pressure of 88/50 mmHg. Which finding should prompt the nurse to notify the provider immediately as a priority indicator of possible septic shock?
- ATemperature of 38.6°C (101.5°F)
- BWhite blood cell count of 14,000/mm3
- CProductive cough
- DBlood pressure of 88/50 mmHg
Show answer & explanationAnswer & explanation
Correct answer: D. Blood pressure of 88/50 mmHg
Hypotension in the setting of suspected infection indicates possible progression to septic shock, a medical emergency requiring immediate fluid resuscitation and vasopressor support. While fever, leukocytosis, and altered mentation support a diagnosis of sepsis, hypotension signals hemodynamic instability that requires urgent action.
Why the other options are wrong
- A. Fever supports an infectious process but is not the most urgent hemodynamic concern.
- B. Leukocytosis confirms infection/inflammation but is not as immediately life-threatening as hypotension.
- C. Productive cough is expected with pneumonia and does not indicate a worsening emergency.
Septic Shock Recognition
Sepsis progresses to septic shock when infection causes persistent hypotension requiring vasopressors despite fluid resuscitation, along with organ dysfunction and altered mentation.
- qSOFA criteria: altered mentation, RR ≥22, SBP ≤100 mmHg
- Hypotension signals hemodynamic compromise requiring urgent fluids/vasopressors
- Early recognition and antibiotics/fluids within the first hour improve survival
Memory trick: Low BP with infection = shock is knocking