A client with suspected sepsis has a BP of 82/48 mm Hg and lactate of 4.2 mmol/L. Which actions should the nurse anticipate in the first hour? Select all that apply.

A. Give broad-spectrum antibiotics
B. Draw blood cultures before antibiotics
C. Wait for culture results before starting antibiotics
D. Restrict fluids to prevent pulmonary edema
E. Infuse 30 mL/kg of IV crystalloid

Show answer and rationale

Correct answers: A, B, E

Sepsis hour-1 bundle: measure lactate, draw blood cultures before antibiotics, start broad-spectrum antibiotics, give 30 mL/kg crystalloid for hypotension or lactate at least 4 mmol/L, and start vasopressors if hypotension persists.

Source: Surviving Sepsis Campaign. Hour-1 Bundle; 2021 Guidelines

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Study emergencies as a sequence: what you see, what it means, what you do first (DKA, sepsis, stroke, PE, anaphylaxis, tension pneumothorax).
Review fluid and electrolyte imbalances by their ECG and neuromuscular signs (peaked T waves, Chvostek and Trousseau signs).

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A client with suspected sepsis has a BP of 82/48 mm Hg and lactate of 4.2 mmol/L. Which actions should the nurse anticipate in the first hour? Select all that apply.

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