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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. The time of the burn helps in understanding how long the client has been exposed and may influence the assessment of burn progression, but it does not directly determine the severity.
B. The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
C. The cause of the burn is important for treatment considerations and understanding the mechanism of injury but does not impact the assessment of burn severity.
D. The location of the burn affects the potential for complications and functional impairment but is secondary to the depth in determining overall burn severity.

A. Initiate droplet precautions. B. Prepare to administer antiviral therapy. C. Assess for hemorrhage. D. Assess the respiratory system.

Correct Answer is D

Explanation

A. Droplet precautions are not appropriate for anthrax exposure. Precautions would be based on the specific form of anthrax (cutaneous, inhalation, or gastrointestinal).
B. Anthrax is treated with antibiotics, not antiviral therapy. Ciprofloxacin or doxycycline is typically used for prophylaxis and treatment.
C. While assessing for hemorrhage might be relevant in cases of severe anthrax, it is more critical initially to focus on respiratory assessment, particularly for inhalation anthrax.
D. Assessing the respiratory system is crucial for clients exposed to anthrax, particularly inhalation anthrax, as it can cause severe respiratory symptoms and complications. Prompt assessment is essential for early detection and treatment of respiratory distress.

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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 assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is B

Explanation

A nurse is caring for a client who has been exposed to anthrax. Which of the following interventions should the nurse plan to use while caring for this client?

Correct Answer is D

Explanation

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