The nurse is evaluating the clients in an intensive care unit for risk for sepsis and septic shock. Clients at risk for sepsis include the client: Select all that apply
1. From a nursing home with a stage 4 pressure ulcer.
2. With rheumatoid arthritis taking methotrexate.
3. With aplastic anemia.
4. With blunt trauma spinal cord injury.
5. With ruptured viscus vomiting bright red blood.
1. From a nursing home with a stage 4 pressure ulcer.
2. With rheumatoid arthritis taking methotrexate.
3. With aplastic anemia.
Rationale: From a nursing home with stage 4 pressure ulcer. Breaches in skin integrity such as pressure ulcers are risks for sepsis and septic shock. With rheumatoid arthritis taking methotrexate. Clients such as those taking methotrexate for chemotherapy or immune modulation are at risk for sepsis and septic shock. With aplastic anemia. Aplastic anemia results in suppression of all cellular elements of the bone marrow, including WBCs, which puts the client at risk for infection and sepsis. With blunt trauma spinal cord injury. Blunt spinal cord injury may lead to spinal or neurogenic shock. With ruptured viscus vomiting bright red blood. Fluid-volume deficit secondary to hematemesis may lead to hypovolemic shock.
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