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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Keeping a body map of skin lesions is a key strategy for monitoring changes in the skin over time. This helps individuals track any new or changing lesions, which is crucial for early detection of skin cancer.
B. Reducing tanning bed use is important because tanning beds are a significant risk factor for skin cancer. However, the instruction should emphasize complete avoidance rather than just reduction, as tanning beds dramatically increase the risk of melanoma.
C. Examining your body every 2 months is not frequent enough for effective skin cancer monitoring. Monthly self-examinations are generally recommended to catch potential changes early.
D. Avoiding the sun after 3 p.m. is incorrect; the most dangerous sun exposure typically occurs between 10 a.m. and 4 p.m. The instruction should advise avoiding the sun during peak hours or wearing protective clothing and sunscreen.
Correct Answer is B
Explanation
A. Decreased prothrombin time is not typically associated with the emergent phase of a burn injury. Prothrombin time changes are more related to liver function or coagulation disorders.
B. Increased hematocrit is common in the emergent/resuscitative phase of burn injury due to fluid shifts and loss of plasma volume, leading to hemoconcentration.
C. Increased sodium is not typically seen in the emergent phase; instead, hyponatremia may occur due to fluid shifts and loss of sodium in the burn exudate.
D. Potassium deficit is more likely to occur later in the burn management phases. In the emergent phase, hyperkalemia is more common due to cell destruction and release of intracellular potassium.
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