b
(Rationale
Oliguria and hypotension are considered part of the cold phase or late septic shock. In this phase, in addition to blood pressure and urine decreases, hypovolemia and compensatory mechanisms result, such as rapid, shallow, or dyspneic respirations. The skin becomes cool, pale, and edematous; the client becomes lethargic to comatose mental status. There is decreased CVP, tachycardia, and arrhythmic pulses, and
normal to decreased body temperatures. Death may occur during this phase due to respiratory, cardiac, and/or renal failure.)
a,b,d,e
(Rationale
Clients with the following portals of entry are at risk for infections that may lead to sepsis: clients with catheterizations, those undergoing respiratory therapies, and those with peptic ulcers, ruptured appendix, peritonitis, surgical wounds, IVs, decubitus ulcers, burns, and traumas. Female clients
with STIs, who use tampons, or who have surgical abortions are at risk for septic shock. Other clients at risk for developing sepsis related to infections are those clients who are hospitalized, have debilitating chronic illnesses, have poor nutritional status, have had an invasive procedure or surgery, and those who are older adults or immunocompromised.)