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

B. Experiencing depression following a disaster is a common response. Survivors often experience a range of emotional responses, including depression, due to the trauma and loss associated with the event.
A. The depression is more likely related to the traumatic event rather than a pre-existing condition.
C. While survivors may struggle with feelings of guilt or disbelief, the focus should be on understanding the depression as a response to the trauma experienced.
D. Although feelings of guilt may be present, it is more pertinent to address the depression as a common mental health issue following a traumatic event.

A. Apply heated compress to the knee. B. Assess client's activated partial thromboplastin time (aPTT). C. Administer low-dose aspirin. D. Prepare for autologous blood transfusion.

Correct Answer is B

Explanation

B. Assessing the client's activated partial thromboplastin time (aPTT) is important to monitor the effectiveness of treatment and manage bleeding risk. Hemophilia A is characterized by a deficiency in clotting factor VIII, which prolongs the aPTT.
A. Applying heated compresses is not recommended for hemarthrosis; instead, cold compresses should be used to reduce bleeding and swelling.
C. Low-dose aspirin is contraindicated for clients with hemophilia because it can further inhibit platelet function and increase bleeding risk.
D. Autologous blood transfusion is not typically required for hemophilia; factor replacement therapy is the standard treatment.

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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)?

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Naxlex Comprehensive Predictor Exams

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