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 C

Explanation

A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.

A. Thiamine B. Vitamin C C. Vitamin K D. Folic acid

Correct Answer is C

Explanation

A. Thiamine deficiency is often associated with neurological symptoms, such as Wernicke-Korsakoff syndrome, rather than spontaneous bleeding or bruising. Thiamine does not directly impact the coagulation process.
B. Vitamin C deficiency can lead to scurvy, which includes symptoms such as bleeding gums and poor wound healing. However, it is not typically associated with the spontaneous bleeding and bruising seen in chronic liver failure.
C. Vitamin K is essential for the synthesis of clotting factors produced by the liver. In chronic liver failure, the liver's ability to produce these factors is impaired, leading to an increased risk of bleeding and bruising due to vitamin K deficiency.
D. Folic acid deficiency is more commonly linked to anemia and certain neurological issues, but it does not cause spontaneous bleeding or bruising. It does not directly affect coagulation factors as vitamin K does.

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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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