A client is diagnosed with systemic inflammatory response syndrome (SIRS) as a result of a bacterial infection. Which nursing intervention may prevent the development of multiple-organ dysfunction syndrome (MODS)?

Placing the client on a ventilator to remove carbon dioxide (CO2)

Advising the client to use their call light to reduce the risk of falls

Providing the client a high protein diet

Administering antibiotics and maintaining the mean arterial pressure (MAP) at least 65 mm Hg

Answer and Explanation

The Correct Answer is D

A. Placing the client on a ventilator to remove CO2 is not directly related to preventing the development of MODS. While ventilation might be necessary for respiratory support, it does not address the systemic infection and inflammation that contribute to MODS.
B. Advising the client to use their call light to reduce the risk of falls is important for general safety but does not address the critical factors involved in preventing MODS in the context of SIRS.
C. Providing a high protein diet can support overall nutrition and healing but is not the primary intervention for preventing MODS. Managing the infection and maintaining hemodynamic stability are more critical.
D. Administering antibiotics to treat the bacterial infection and maintaining a mean arterial pressure (MAP) of at least 65 mm Hg are essential interventions. Effective antibiotic therapy addresses the infection, and maintaining MAP ensures adequate organ perfusion, both of which help prevent the progression to MODS.

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Correct Answer is B

Explanation

A. Consulting with a healthcare provider before taking over-the-counter medications is appropriate, as some medications can affect blood glucose levels or interact with diabetes medications.
B. It is crucial for clients with diabetes to continue taking insulin during illness, even if they are unable to eat. Insulin needs may increase due to stress or infection, and not taking insulin could lead to hyperglycemia or diabetic ketoacidosis. Checking blood sugar every 2 hours is correct, but insulin should not be omitted.
C. Calling the doctor if the illness lasts longer than 2 days is a good practice, as prolonged illness can affect diabetes management and may require medical intervention.
D. Calling the doctor if blood sugar is over 250 mg/dL or if there is protein in the urine is appropriate, as these conditions can indicate complications that need medical attention.

A. "I will keep the temperature in my house cold to avoid becoming overheated." B. "I will follow my prescribed medication regimen and inform my healthcare provider of any side effects." C. "I will try to manage my stress levels through relaxation techniques and therapy." D. "I will make sure to wear protective clothing when I go outside."

Correct Answer is A

Explanation

A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is crucial for managing SLE and preventing flare-ups. This demonstrates the client's understanding of the importance of medication adherence.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is known to exacerbate SLE. This statement reflects an understanding of the need to reduce stress to manage the disease effectively.
D. Wearing protective clothing when going outside is essential to prevent sun exposure, which can trigger SLE flare-ups. This indicates that the client understands the need for sun protection.

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A client is diagnosed with systemic inflammatory response syndrome (SIRS) as a result of a bacterial infection. Which nursing intervention may prevent the development of multiple-organ dysfunction syndrome (MODS)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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