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. 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.

A. Labrynthitis B. Perforated tympanic membrane C. Meniere disease D. Otitis externa

Correct Answer is B

Explanation

A. Labrynthitis is an inner ear disorder that causes vertigo, tinnitus, and hearing loss, but it does not typically involve otorrhea (ear discharge) or the sudden resolution of ear pain.
B. A perforated tympanic membrane is characterized by a sudden relief of ear pain when the eardrum ruptures, often accompanied by otorrhea (discharge from the ear). This condition is typically the result of an infection that increases pressure in the middle ear until the eardrum bursts.
C. Meniere disease involves episodes of vertigo, tinnitus, and fluctuating hearing loss, but does not usually present with ear pain followed by discharge.
D. Otitis externa, or swimmer’s ear, involves inflammation of the ear canal with symptoms like pain, itching, and discharge, but does not cause the sudden resolution of pain following the onset of otorrhea.

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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

A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved with a new onset of otorrhea. The nurse should recognize the client has manifestations of which condition?

Correct Answer is B

Explanation

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