Chapter 66
1. The nurse is evaluating the effectiveness of a continuous infusion of insulin for a patient diagnosed with multiple organ dysfunction syndrome (MODS). Which blood glucose value would indicate an acceptable level in this situation?
156 mg/dL
156. How should the nurse meet the nutritional and metabolic needs of a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Carry out stress ulcer prophylaxis in the patient. · Monitor abdominal distention and intraabdominal pressure. · Monitor plasma transferrin and prealbumin levels frequently.
1. A nurse is monitoring a patient for signs and symptoms related to septic shock. Which are late signs of this emergency condition? Select all that apply.
· Cool and mottled skin · Myocardial dysfunction
1. Which findings in a patient with systemic inflammatory response syndrome (SIRS) help the nurse identify cardiovascular system dysfunction? Select all that apply.
· Decrease in blood pressure · Decrease in mean arterial pressure · Decrease in systemic vascular resistance
1. Which interventions might the nurse anticipate implementing to prevent healthcare-associated infections for a patient suffering from multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Early surgery to remove necrotic tissue · Ambulating patient as early as possible · Daily assessment of continuing need for invasive lines and devices · Strict use of aseptic and sterile technique in relation to lines and tubes
1. What are the immediate effects of the inflammatory response that precedes multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Hypermetabolism · Increased vascular permeability · Direct damage of the endothelium
1. What are the results of hypermetabolic response in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Hypoglycemia · Hyperglycemia · Glycogenolysis · Gluconeogenesis
1. A patient being cared for in the critical care unit for pancreatitis and subsequent development of multiple organ dysfunction syndrome (MODS) is exhibiting gastrointestinal symptoms including bleeding. Which prescriptions does the nurse anticipate the healthcare provider will order to address the gastrointestinal issues? Select all that apply.
· Maalox · Sucralfate · Omeprazole
1. Which types of shock are associated with decreased cerebral perfusion? Select all that apply.
· Obstructive shock · Cardiogenic shock · Hypovolemic shock
156. The nurse is reviewing lab results for a patient in the critical unit to monitor for possible development of multiple organ dysfunction syndrome (MODS). Which lab results would indicate possible development of MODS to the nurse? Select all that apply.
· PAWP 15 mmHg · Platelets 100,000 uL · Urine specific gravity 1.042
156. The nurse is evaluating lab results related to the hematologic system for a patient diagnosed with multiple organ dysfunction syndrome (MODS) following a traumatic injury. Which lab results indicate involvement of the hematologic system? Select all that apply.
· PT 18 sec · D-dimer 280 ng/mL · Platelets 125 x 10/uL
1. A patient in cardiogenic shock is prescribed a dose of sodium nitroprusside. What appropriate actions should the nurse perform to safely administer sodium nitroprusside? Select all that apply.
· Protect solution from light. · Wrap infusion bottle with opaque covering. Monitor the serum cyanide levels and signs of cyanide toxicity.
1. Which findings indicate the development of acute respiratory distress syndrome (ARDS) in a patient with systemic inflammatory response syndrome (SIRS)? Select all that apply.
· Pulmonary hypertension · Decreased lung compliance · Bilateral diffuse infiltrates in the chest
1. Vasopressor agents are prescribed for which types of shock? Select all that apply.
· Septic shock · Neurogenic shock
156. A patient who suffered multiple fractures from a vehicle accident is being observed for potential development of multiple organ dysfunction syndrome (MODS). Which assessment data would indicate potential development of the syndrome? Select all that apply.
· Severe dyspnea · Respiratory rate of 32 breaths/minute · Heart rate of 110 beats/minute · Blood pressure of 86/42 mmHg
1. When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy? Select all that apply.
· Start enteral nutrition within the first 24 hours. · Start parenteral nutrition if enteral feedings are contraindicated. · Start a slow continuous drip of small amounts of enteral feedings.
1. Which should the nurse evaluate when performing an assessment of end organ function on a patient who received fluid volume resuscitation for septic shock? Select all that apply.
· Urine output · Peripheral pulses · Neurologic function
1. A patient is receiving 5% human serum albumin. The nurse should monitor for which complications associated with the infusion? Select all that apply.
· Urticaria · Fluid overload
1. Which are pathophysiologic effects of septic shock? Select all that apply.
· Vasodilation · Myocardial depression · Maldistribution of blood flow
1. The health care provider prescribes a dose of dobutamine for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication? Select all that apply.
· Administer through a central line. · Monitor heart rate and blood pressure. · Stop infusion if tachydysrhythmia develop.
1. When planning for home care of a patient who has just recovered from shock, what appropriate measures should the nurse follow? Select all that apply.
· Admit to rehabilitation center. · Arrange for transitional care units. · Refer to home health care agencies.
156. When caring for a patient with multiple organ dysfunction syndrome, what treatment should the nurse anticipate for stress ulcer prophylaxis? Select all that apply.
· Antacids · Sucralfate · Proton pump inhibitors
1. A patient is admitted to the hospital with a suspected diagnosis of obstructive shock. What could be the possible causes of this type of shock? Select all that apply.
· Cardiac tamponade · Tension pneumothorax · Superior vena cava syndrome
1. The certified nursing assistant (CNA) reports that bright red blood has been found in the stool of a patient diagnosed with multiple organ dysfunction syndrome (MODS). The CNA asks the nurse about the cause of the blood in the stool. Which explanation by the nurse is most accurate?
"Decreased oxygen to the gastric mucosa leads to breakdown."
1. A nurse is caring for a patient diagnosed with septic shock. The patient weighs 75 kg. The healthcare practitioner orders intravenous (IV) fluid resuscitation of 30 mL/kg. How many milliliters will the nurse infuse? Record your answer using a whole number and no punctuation.
2250 mL
1. A nurse is caring for a patient diagnosed with septic shock. After an infusion of 30 mL/kg of intravenous fluids, the patient is assessed and has a temperature of 101.4°F (38.6°C), a heart rate of 92 beats/minute, respiration rate of 20 breaths/minute, and a blood pressure of 80/60 mm Hg. Which nursing intervention is a priority for this patient?
Administer a vasopressor.
1. The nurse is taking care of a patient with cardiogenic shock due to a myocardial infarction. The health care provider prescribes dopamine to be administered. What nursing intervention should the nurse perform for administering dopamine? Select all that apply. ·
Administer via a central line. · Monitor for tachydysrhythmias. · Monitor for peripheral vasoconstriction.
1. A nurse is reviewing the chart of a 68-year-old patient admitted with pneumonia. The nurse knows that the patient has the potential to develop sepsis based on which risk factors?
Age
1. A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient?
Aggressive IV crystalloid fluid resuscitation
1. What action should the nurse take when caring for a patient with multiple organ dysfunction syndrome (MODS)?
Aim for glycemic control at 140 to 180 mg/dL.
1. A patient has neurologic dysfunction related to sepsis. Which assessment finding is specific to this dysfunction?
Altered mental status
1. A nurse is caring for multiple patients. Which patient does the nurse monitor most closely for possible development of sepsis?
An 86-year-old patient with a fever and history of chronic urinary tract infections
1. A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as?
Anaphylactic shock
1. Which form of shock is associated with pruritus?
Anaphylactic shock
1. The nurse is caring for a patient who has hypovolemic shock from hemorrhage. The nurse expects to find which clinical manifestation(s)? Select all that apply. ·
Anxiety · Tachycardia · Hypotension · Decreased capillary refill
1. Which type of organism most commonly causes sepsis?
Bacteria
156. The nurse is assessing a patient receiving care following a trauma. The patient had been suffering from paralytic ileus and has developed multiple organ dysfunction syndrome (MODS). Which lab finding indicates to the nurse that persistent hypermetabolism is occurring?
Blood glucose of 65 mg/dL
1. What type of medication does the nurse anticipate being prescribed by the health care provider to manage confusion, disorientation, and delirium in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Calcium channel blockers
1. A nurse is assessing a patient admitted with septic shock. The nurse notes the patient is anxious, confused, and agitated. The nurse knows that these symptoms are signs of impairment of which process?
Cerebral perfusion
1. Which sign of neurologic dysfunction is commonly seen in both systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Confusion, agitation, and lethargy
1. Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Hypotension
1. Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS)?
Decrease in capillary refill
156. A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed-head injury. Which clinical manifestation warns the nurse that the patient's condition is progressing to multiple organ dysfunction syndrome (MODS)?
Decreased PaO2 with an increase in FiO2
1. A student nurse is caring for a patient diagnosed with sepsis. The student nurse tells the nurse the care plan regarding the administration of antibiotics. Which nursing action requires correction?
Delay antibiotics administration if the causative organism is unknown.
1. A nurse is caring for a patient diagnosed with septic shock. For which sign of peripheral hypoperfusion does the nurse assess the patient?
Diaphoresis
156. A patient who suffered a massive myocardial infarction two weeks ago developed multiple organ dysfunction syndrome three days ago. Despite mechanical ventilation, sedation, and nutritional and cardiac support, the patient has not responded. The primary care provider has indicated that further interventions will likely be unsuccessful. Which option does the nurse anticipate being discussed next with the patient's family?
Discussion of life support withdrawal and initiation of end-of-life care.
1. A patient is showing signs of anaphylactic shock from an insect sting. Which health care provider's order does the nurse implement first ?
Epinephrine 1:1000, 0.5 mg IM
1. Why is there a loss of lean body mass in patients with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS)?
Fatty acids are mobilized for fuel.
1. A patient receiving care for multiple organ dysfunction syndrome (MODS), which has affected the respiratory, cardiac, and renal systems is receiving medications to address renal manifestations. Which prescription is indicated to address these issues?
Furosemide
1. Which drug helps manage renal manifestations in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Furosemide
1. The nurse is mentoring a graduate nurse and is explaining the use of fluids in a patient who is experiencing hypovolemic shock. Which of the following fluids increases osmotic pressure to provide rapid volume expansion?
Human serum albumin
1. The nurse would recognize which clinical manifestation as suggestive of sepsis?
Hyperglycemia in the absence of diabetes
1. When reciting to the nursing instructor mechanisms that can trigger the systemic inflammatory response syndrome (SIRS) associated with sepsis, which listed by the student nurse requires correction?
Hypertension
1. Which type of shock causes an absence of bowel sounds?
Hypovolemic shock
1. What laboratory finding correlates with a medical diagnosis of cardiogenic shock?
Increase blood urea nitrogen (BUN) and serum creatinine levels
1. A nurse is caring for a patient in the intensive care unit (ICU) admitted with septic shock. The patient has been in the ICU for 36 hours. After 24 hours, which finding increases the patient's risk for developing multiple organ dysfunction syndrome (MODS)?
Increased cardiac output
1. Which criterion is a clinical manifestation of sepsis?
Infection
1. The the nurse knows that which acid-base imbalance occurs in multiple organ dysfunction syndrome (MODS) due to impaired tissue perfusion, hypoxia, and increased lactate levels?
Metabolic acidosis1.
1. A patient being cared for in the critical care unit following a fall from a ladder which caused a severe fracture of the left tibia, several rib fractures, and splenic bruising is being assessed by the nurse. The family reports that the patient seems confused and has become agitated. The nurse notes that the patient's oxygen saturation is decreasing, respiratory rate is 30, blood pressure is 86/50 mm Hg, and capillary refill is greater than 3 seconds. What does the nurse suspect may be occurring with this patient?
Multiple organ dysfunction syndrome
1. Which medical emergency is caused by the failure of two or more organ systems?
Multiple organ dysfunction syndrome (MODS)
1. Which type of shock can be treated by minimizing spinal cord trauma with stabilization?
Neurogenic shock
1. A nurse caring for a patient with multiple organ dysfunction syndrome understands that the patient may be at increased risk of bleeding. What nursing interventions should the nurse perform to manage this patient? Select all that apply. ·
Observe bleeding sites. · Minimize traumatic interventions. · Administer platelets and clotting factors.
1. The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning?
PaO2 60 mmHg
1. When examining a patient with septic shock, what symptoms would the nurse expect to find? Select all that apply. ·
Paralytic ileus · Decreased urinary output · Gastrointestinal (GI) bleeding
156. Which patient being cared for by the nurse in a critical care unit would the nurse suspect may have multiple organ dysfunction syndrome (MODS)?
Patient A- (Burns over 30% of total body surface area, BUN/creatinine ratio 24:1; spec gravity 1.032, dyspnea, tachypnea, PAWP 14 mmHg)
1. A patient diagnosed with septic shock receives aggressive fluid resuscitation. The nurse performs a passive leg raise challenge to assess which process?
Patient responsiveness to fluids
1. The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). Which interventions to prevent and treat infection are appropriate to be included on the patient's plan of care? Select all that apply. ·
Placing the patient under stress ulcer prophylaxis. · Removing necrotic tissue through aggressive surgery · Maintaining strict sepsis of invasive devices and procedures · Assessing the ongoing need for invasive lines and other devices daily.
1. Which laboratory level would indicate dysfunction of the hematologic system in a patient with multiple organ dysfunction syndrome (MODS), by its decrease?
Platelet count
1. A nurse is developing a care plan for optimum nutrition for a patient with multiple organ dysfunction syndrome (MODS) caused by sepsis. Which nutritional combination is most appropriate for this patient?
Protein and calories
1. What is the clinical manifestation of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) on the respiratory system?
Pulmonary hypertension
1. Which manifestation in a patient with systemic inflammatory response syndrome (SIRS) suggests respiratory system dysfunction?
Refractory hypoxemia
1. What organ system is often the first to show signs and symptoms in multiple organ dysfunction syndrome (MODS)?
Respiratory
1. Which system of the body is often the first to show signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Respiratory system
1. Which system shows initial signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Respiratory system
1. What is the most commonly reported cause for death in patients with multiple organ dysfunction syndrome (MODS)?
Sepsis
156. What laboratory value may be increased in a patient with systemic inflammatory response syndrome (SIRS) who has hepatic dysfunction?
Serum alanine aminotransferase
1. Which laboratory value may indicate, by its decrease, hepatic dysfunction in a patient with systemic inflammatory response syndrome (SIRS)?
Serum transferrin
1. How is systemic inflammatory response syndrome (SIRS) different from multiple organ dysfunction syndrome (MODS)? .
Shock leads to SIRS, and SIRS causes MODS
1. Which assessment findings make the nurse suspect cardiovascular dysfunction in a patient with systemic inflammatory response syndrome (SIRS)?
The patient has skin mottling
1. The nurse reviews the plan of care for a patient with multisystem organ dysfunction syndrome. What is the most desirable outcome for the patient?
The patient will demonstrate improved perfusion and oxygenation of organs.
1. For a patient to be diagnosed with multiple organ dysfunction syndrome (MODS), how many organ systems must be simultaneously failing?
Two
1. Which cardiovascular change occurs in a patient with systemic inflammatory response syndrome (SIRS)?
Warm skin
156. What finding in the laboratory reports of a patient with multiple organ dysfunction syndrome (MODS) suggests to the nurse that the patient has acute tubular necrosis?
Urine Na+ is 22 mEq/L
1. Systemic inflammatory response syndrome (SIRS) in a patient seems to have progressed to dysfunction of the renal system. How are the manifestations of acute tubular necrosis different from those of renal hypoperfusion?
Urine specific gravity is around 1.010 in acute tubular necrosis and greater than 1.020 in renal hypoperfusion.
1. When choosing a vasopressor for a septic patient who is not responsive to fluid resuscitation, which drug would the nurse expect the healthcare provider to most likely order?
Norepinephrine
1. When using an isotonic fluid replacement for a patient who is in shock, what are important interventions that a nurse should perform? Select all that apply.
· Monitor the patient closely for circulatory overload. · Avoid using Lactated Ringer's solution in patients with liver failure.
1. A patient is suspected to have septic shock due to untreated cellulitis in the lower extremity. What findings would the nurse expect to observe when assessing this patient? Select all that apply.
· Crackles · Hyperventilation · Decreased urine output
1. When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect? Select all that apply.
· Cyanosis · Cold skin · Weak pulse
1. Which types of shock may cause reduced urinary output in a patient? Select all that apply.
· Septic shock · Obstructive shock · Cardiogenic shock · Hypovolemic shock
1. Which drug causes arterial and venous dilation?
Sodium nitroprusside
1. A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of which condition?
Cardiogenic shock
1. Septic shock is classified as which type of shock?
Distributive
1. A patient has been brought to the emergency department (ED) in a semiconscious state. The history collected from family members indicates that the patient consumed shellfish after which he experienced itching, difficulty breathing, and confusion. What treatment should the nurse anticipate for this patient? Select all that apply. ·
Famotidine · Epinephrine · Diphenhydramine
1. A nurse is evaluating a patient admitted with sepsis who received large amounts of fluid resuscitation in the emergency room. Which is the priority for the nurse to evaluate concerning possible complications caused by large fluid volume administration?
Hypothermia and coagulopathy
1. A patient in septic shock is receiving fluid resuscitation. How will the nurse most accurately measure urine output?
Indwelling urinary catheter
1. A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?
Ineffective tissue perfusion
1. When caring for a patient in acute septic shock, what should the nurse anticipate?
Infusing large amounts of intravenous (IV) fluids
1. When caring for a patient with sepsis and a suspected infection, which is the priority nursing intervention?
Initiate broad spectrum antibiotics
1. What therapy is provided to a patient with acute respiratory distress syndrome (ARDS)?
Mechanical ventilation
1. What occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)?
Release of mediators
1. When a patient suffers from hypovolemic shock due to loss of blood, the nurse should administer large volumes of packed red blood cells (RBCs). What should be the appropriate course of action for the nurse?
Replace clotting factors based on laboratory studies.
1. The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings?
The patient has septic shock
1. Multiple organ dysfunction syndrome (MODS), a complication of sepsis, is the failure of how many organ systems?
Two or more
1. When working in an acute medical setting, which patients should a nurse consider to be prone to a risk of developing septic shock? Select all that apply.
· A 55-year-old with diabetes · A 45-year-old with heart failure · A 70-year-old with malnourishment · An 80-year-old with a compromised immune system
1. A patient diagnosed with multiple organ dysfunction syndrome (MODS) is severely dyspneic, tachycardic, hypotensive, confused, and disoriented. The patient's family asks the nurse why the patient is being prescribed amlodipine. Which response by the nurse is most appropriate?
"Amlodipine is being used to reduce cerebral vasospasm."
1. The family of a critically ill patient receiving enteral nutrition to support nutritional and metabolic needs ask the nurse why a feeding tube is being used instead of intravenous (IV) feedings. Which response by the nurse best explains the basis for enteral versus parenteral feedings?
"Providing feedings through a gastrostomy tube is safer and has a lower rate of infection."
1. The nurse is reviewing the prescriptions of a patient being treated for multiple organ dysfunction syndrome (MODS). Which medication listed does the nurse expect is being used to manage cardiac manifestations?
Dobutamine
1. Patients in septic shock require large amounts of fluid replacement. The nurse would expect the healthcare practitioner to order an amount of fluids in which range to achieve adequate fluid resuscitation?
30-50 mL/kg
1. What causes gut bacteria to move into circulation in patients with systemic inflammatory response syndrome (SIRS)?
Decreased perfusion of gut mucosa.
1. If the patient in shock is to receive 1000 mL of normal saline in two hours, at what rate should the infusion pump e set? Record your answer using a whole number. mL/hour.
500 mL/hour
1. A nurse is caring for a 60-year-old patient with sepsis stemming from cellulitis to the right lower extremity. The patient's core temperature is 101.6° F (38.8° C). Which strategy to reduce the patient's temperature should the nurse implement?
Administer antipyretics.
1. When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)?
Decreased respiratory compliance
1. A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform?
Begin crystalloid fluid replacement.
1. A nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) caused by sepsis. Which is the most appropriate communication with the caregiver when further treatment is futile?
Discuss realistic goals and likely outcomes.
1. The nurse is reviewing orders for laboratory work for a patient who is experiencing shock. Which of the following tests would the nurse expect to be ordered? Select all that apply. ·
Creatinine · Arterial blood gases · Complete blood count
1. The release of platelet-activating factors in patients who have sepsis triggers which response?
Formation of microthrombi
1. Which medication would the nurse administer to treat renal complications associated with systemic inflammatory response syndrome (SIRS)?
Furosemide
1. What causes dysrhythmias in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?
Hypokalemia due to activities of aldosterone and catecholamines
1. What electrolyte change is likely in patients with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS)?
Hypophosphatemia
1. A patient diagnosed with sepsis fails to respond to fluid resuscitation. The healthcare provider orders the patient to be started on a vasopressor. The nurse evaluates which response to determine the effectiveness of the vasopressor?
Mean arterial pressure greater than 65 mmHg
1. A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient?
Monitor for signs of circulatory overload
1. When considering the use of nitroglycerin for treating a patient with shock, what actions should the nurse perform? Select all that apply. ·
Monitor the heart rate. · Monitor the blood pressure. · Use a glass bottle for infusion.
1. A patient in neurogenic shock is receiving phenylephrine. Which nursing actions are appropriate when caring for this patient?
Monitoring for signs of reflex bradycardia and restlessness
1. The nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect?
Myocardial infarction
1. Which type of shock is associated with bradycardia?
Neurogenic shock
1. A patient is diagnosed with multiple organ dysfunction syndrome. While aggressive treatment is continued, the nurse suspects infection. What is the most appropriate action that the nurse should perform?
Obtain a prescription for broad-spectrum antibiotic therapy.
1. A patient with multiple organ dysfunction syndrome (MODS) has a temperature of 102.2 o F and has copious amounts of purulent drainage and redness surrounding a diabetic wound on the right foot. Of the prescribed options, which action should be the nurse's priority action?
Obtain wound and blood cultures.
1. The nurse is creating a care plan to prevent infections in a patient currently receiving ventilator support for multiple organ dysfunction syndrome (MODS). Which intervention would the nurse include to most effectively reduce the chance of respiratory complications?
Place the patient in a continuous motion bed frame.
1. The intensive care unit nurse is caring for a patient who is ventilated mechanically. To prevent sepsis in this patient, which nursing intervention does the nurse include in the plan of care?
Provide oral care every two to four hours.
156. The nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) who exhibits signs of cardiovascular dysfunction. Which interventions are appropriate for volume management in the patient? Select all that apply. ·
Providing volume replacement therapy · Monitoring arterial pressure-based cardiac output (APCO) · Using central venous catheter for hemodynamic monitoring
1. Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care?
Pulmonary artery pressure (PAP) 28/14 mmHg
1. A nurse is caring for a patient diagnosed with septic shock. The patient develops dyspnea, tachycardia, and bilateral lung crackles. The nurse suspects the patient has developed acute respiratory distress syndrome (ARDS). Which intervention is the nurse's priority?
Pulmonary management with mechanical ventilation
1. Which term is used to describe a constellation of symptoms or a syndrome in response to an infection characterized by a dysregulated patient response along with new organ dysfunction?
Sepsis
1. The primary health care provider prescribes antibiotics and vasopressors for a patient. Which type of shock does the nurse expect to be treating?
Septic shock
1. Which term is used to describe persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia?
Septic shock
1. The nurse is caring for a patient who has hypovolemic shock. Which medical diagnosis does the nurse suspect?
Severe burns
1. In a patient diagnosed with septic shock, which manifestations are initial compensatory mechanisms of the respiratory system? Select all that apply.
· Tachypnea · Hyperventilation
1. Which supportive therapies does a patient admitted with septic shock require? Select all that apply. ·
Stress ulcer prophylaxis · Good blood glucose control · Aggressive fluid resuscitation · Close temperature monitoring · Blood cultures before antibiotics
1. A patient diagnosed with multiple organ dysfunction syndrome is developing pulmonary edema. The nurse realizes that which factor is the cause of the edema?
Uncontrolled systemic inflammation
1. Which laboratory finding in a patient with multiple organ dysfunction syndrome (MODS) suggests prerenal manifestations of renal dysfunction?
Urine specific gravity is increased.
1. When using dextran as a fluid therapy for a patient who is in a state of shock, which factors should the nurse consider? Select all that apply. ·
Use of dextran as a fluid therapy increases the risk of bleeding. · Use dextran in limited quantities for shock therapy because it has side effects. · Check whether the patient is monitored for allergic reactions and acute renal failure.
1. What causes acute kidney injury (AKI) in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply. ·
Use of nephrotoxic drugs · Effect of inflammatory mediators · Decreased perfusion to the kidneys
1. The nurse recalls that cardiogenic shock is differentiated from other forms of shock because the patient with cardiogenic shock typically experiences what?
Volume excess
1. What actions should the nurse take to optimize tissue oxygenation in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Advise the patient to rest. · Administer sedatives to the patient.
1. Which nursing interventions are appropriate to manage hematologic dysfunctions in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Avoiding multiple venipunctures · Minimizing intramuscular injections
1. What laboratory findings of a patient with systemic inflammatory response syndrome (SIRS) suggest progression to hepatic dysfunction? Select all that apply.
· Increase in serum ammonia · Decrease in serum transferrin
156. The nurse has obtained the liver function test report of a patient with multiple organ dysfunction syndrome. What hepatic parameters is the nurse likely to find in the laboratory report? Select all that apply.
· Increased liver enzymes · Increased ammonia (NH3) · Increase bilirubin greater than 2 mg/dL
1. A nurse is taking care of a patient with hypovolemic shock from a motor vehicle accident (MVA). The health care provider prescribes human serum albumin for fluid replacement. What should the nurse do to safely administer this medication? Select all that apply.
· Monitor for circulatory overload. · Use 5% solution of serum albumin. · Monitor for chills, fever, and urticaria.
1. A nurse is caring for a 52-year-old patient receiving chemotherapy for lung cancer. Which strategies should the nurse take to reduce the risk for opportunistic infections thereby reducing the risk of sepsis? Select all that apply.
· Pay strict attention to thorough handwashing. · Use aseptic technique during invasive procedures. · Thoroughly clean or discard equipment between patients.
1. A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply.
· Pruritus · Flushing · Urticaria
156. A diabetic patient being cared for following amputation of the left lower leg has large amounts of purulent drainage from the stump and redness and edema around the stump wound. The patient is lethargic and confused. Vital signs include a blood pressure of 80/60 mm Hg, respiratory rate of 32 breaths/minute, and pulse of 112 beats/minute. Which signs and symptoms would support a diagnosis of multiple organ dysfunction syndrome (MODS)? Select all that apply.
· Pulse of 112 beats/minutes · Respiratory rate of 32 breaths/minute · Blood pressure 80/60 mmHg · Lethargic and confused
1. Vasopressin has been prescribed for a patient in septic shock. What nursing interventions are important for this patient? Select all that apply.
Do not titrate. · Infuse at low doses. · Use in vasopressor-refractory patients.
1. A nurse is caring for a patient with sepsis. Which laboratory value will the nurse monitor to measure the byproduct of anaerobic metabolism caused by significant hypoperfusion and impaired oxygen utilization at the cellular level?
Lactic acid
1. The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply.
· Cardiac output · Available hemoglobin· Arterial oxygen saturation
1. The health care provider prescribes 5% sodium chloride solution for the initial fluid replacement in a patient with hypovolemic shock. Which factors should the nurse consider when administering this solution to the patient? Select all that apply.
· Infuse solution through a central line. · Monitor the patient closely for signs of hypernatremia.
1. The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply. ·
Cardiac output · Available hemoglobin · Arterial oxygen saturation
1. Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)?
Cardiogenic
1. The nurse is caring for a patient with a tension pneumothorax. The nurse recognizes that the symptoms of tachypnea, decreased blood pressure, and decreased urine output are caused by which type of shock?
Obstructive
1. What is the goal in the care of a systemic inflammatory response syndrome (SIRS) patient whose bilirubin level is 3 mg/dL? .
Patient will maintain adequate tissue perfusion
1. While planning the management of oxygen delivery in a patient with shock, what appropriate measures should the nurse undertake? Select all that apply.
· Administer supplemental oxygen as prescribed. · Space activities that increase oxygen consumption. · Monitor continuously by using a central venous catheter.
1. A nurse is caring for a patient who is in a state of cardiogenic shock caused by myocardial infarction. The nurse uses pulse oximetry to monitor the oxygen saturation levels. Where should the nurse attach the pulse oximetry probe to get an accurate reading? Select all that apply.
· Ear · Nose · Forehead
1. A pregnant patient is hospitalized with severe hemorrhage. The nurse expects what laboratory results? Select all that apply.
· Increased lactate levels · Decreased hematocrit levels
156. The family of a patient being treated for multiple organ dysfunction syndrome (MODS) asks the nurse why the patient is being sedated and placed on mechanical ventilation. Which explanation by the nurse provides the best explanation for the anticipated outcomes secondary to these interventions?
"Sedation and mechanical ventilation help to decrease oxygen demands and increase oxygen delivery to organs."
1. The nurse is teaching a group of nursing assistive personnel about nutritional support for patients diagnosed with multiple organ dysfunction syndrome (MODS). Which statement by the nurse reflects the overall goal of nutritional support in patients with MODS?
"The overall goal of nutritional support in MODS is to preserve organ function."
156. An instructor working with nursing students in the critical care unit is assessing their knowledge of multiple organ dysfunction syndrome (MODS). Which statement indicates correct understanding of the concept?
"We would generally see dyspnea, changes in pulmonary artery wedge pressure (PAWP), tachypnea, and a decreasing PaO2/FIO ratio as early signs."
1. A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this?
Cardiogenic shock
1. What is the best intervention for a patient with multiple organ dysfunction syndrome (MODS), renal failure, and signs of hemodynamic instability?
Continuous renal replacement therapy
1. When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply.
· Increased risk of GI bleeding · Increased likelihood of GI ulcers · Increased risk of bacterial migration from the GI tract to the bloodstream.
1. A nurse has received the laboratory work of a patient who is suspected to have hypovolemic shock. What would be the laboratory findings if the patient is in the early stages of hypovolemic shock? Select all that apply.
· Increased sodium levels · Increased glucose levels · Decreased potassium levels
1. The nurse is monitoring a patient with neurogenic shock caused by a spinal cord injury. The nurse finds that the PaO 2 is below 60 mm Hg. How should the nurse interpret this finding? Select all that apply.
· Need for higher oxygen concentrations · Need for intubation and mechanical ventilation Need for a different mode of oxygen administration
1. A nurse is assessing a patient who is suspected of having hypovolemic shock. What are the conditions that can cause hypovolemic shock? Select all that apply.
· Ruptured spleen · Bowel obstruction · Diabetes insipidus
156. When managing hypoxemia in a patient with multiple organ dysfunction syndrome, what appropriate interventions should the nurse use to decrease oxygen demand? Select all that apply.
· Sedate the patient. · Administer analgesics. · Initiate mechanical ventilation.
1. A nurse caring for a patient with sepsis completes an intravenous fluid infusion as ordered. Which is a goal for fluid resuscitation when caring for a patient diagnosed with sepsis?
Restore tissue perfusion
