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.
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Related Questions
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.
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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