Question 1

A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F.What nursing intervention is priority?

Accepted Answer

A) Cover the patient with a warming blanket. 
B) Communicate with the provider. 
C) Increase frequency of turning and repositioning the patient. 
D) Increase the amount of humidification given via the ventilator. B

Question 2

Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction syndrome (MODS)in a critically ill patient who is being mechanically ventilated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

A) Enforcing hand washing before and after touching a patient 
B) Following an evidence-based ventilator bundle 
C) Using urinary catheters to prevent perineal skin breakdown 
D) Complying with turning and repositioning schedules 
E) Restricting visitors to immediate family only A,B,D

Question 3

A patient develops systemic inflammatory response syndrome (SIRS)after acute pancreatitis.The patient's wife says,"I thought he didn't have any infection." How should the nurse respond?

Accepted Answer

A) "He probably had an infection that we did not recognize." 
B) "He developed SIRS after getting multiple organ dysfunction syndrome." 
C) "Infection isn't necessary to develop SIRS,only a severe inflammation." 
D) "Your husband's body is working against itself." C

Question 4

The nurse is caring for a patient with multiple organ dysfunction syndrome.Which interventions would help optimize tissue perfusion for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

A) Assess pulse oximetry. 
B) Maintain patency of the endotracheal tube. 
C) Administer pain medications as scheduled. 
D) Keep the environment calm and quiet. 
E) Maintain a darkened environment.

Question 5

The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome (SIRS).Which assessment findings would increase the patient's risk of developing this syndrome?

Accepted Answer

A) Age 36 
B) Body mass index of 23 
C) Asian ancestry 
D) History of Crohn's disease

Question 6

A hospitalized patient develops multiple organ dysfunction syndrome (MODS).Which assessment findings would be the best indication of oxygenation status? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

A) Absence of central cyanosis 
B) Decreased bowel sounds 
C) Unlabored respirations 
D) Mental slowing 
E) Normal pulse amplitude

Question 7

A patient is in the intensive care unit with multiple organ dysfunction syndrome.Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system?

Accepted Answer

A) Increased flatus 
B) Abdominal cramps 
C) Absent bowel sounds 
D) Complaint of epigastric burning

Question 8

A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome.Which laboratory results would confirm the nurse's suspicion of hepatic involvement?

Accepted Answer

A) Increased fibrinogen level 
B) Decreased blood urea nitrogen 
C) Increased serum bilirubin 
D) Increased serum albumin

Question 9

A patient admitted with an infected wound is demonstrating signs of improvement.The nurse would attribute this improvement to which physiologic process?

Accepted Answer

A) Cortisol released from the adrenal glands 
B) Hypothalamus activating white blood cells 
C) Endothelial cells releasing mediators to contain the infection 
D) Mediators that decrease permeability of vessel walls

Question 10

The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with multiple organ dysfunction syndrome (MODS).Which information must the nurse obtain before this measurement can be calculated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

A) Heart rate 
B) Central venous pressure 
C) Mean arterial pressure 
D) Temperature 
E) PaFiO2

Question 11

A patient who underwent transurethral resection of the prostate 5 days ago comes to the emergency department with the report of feeling "worse than before the surgery." After assessing the patient and obtaining laboratory results,the nurse notes a temperature of 96.6°F,a respiratory rate of 26,and a white blood cell (WBC)count of 3000 mm3.The nurse anticipates additional treatment for which disorder?

Accepted Answer

A) Systemic inflammatory response syndrome 
B) Homeostasis 
C) Localized inflammation 
D) Multiple organ dysfunction syndrome

Question 12

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury.Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome (MODS)?

Accepted Answer

A) Urine output less than 400 mL/day 
B) Decreased PaO2 with an increase in FiO2 
C) Alteration in level of consciousness 
D) Hypotension that responds to fluids

Question 13

A patient with a foot infection says,"I can hardly walk on my foot because it is stiff and swollen." What nursing response is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

A) "Infections in the foot always swell because of gravity." 
B) "The swelling and pain help remind you not to overuse your foot." 
C) "That is a sign of infection that would not have occurred if the area was only inflamed." 
D) "Swelling indicates that your infection is getting worse." 
E) "Inflammation often causes pain and tissue swelling."

Question 14

A patient has developed multiple organ dysfunction syndrome (MODS).The nurse would monitor for development of which classic coagulation system findings?

Accepted Answer

A) Large pulmonary emboli 
B) Deep vein thrombosis 
C) Clots in microcirculation 
D) Clot occlusion of coronary arteries

Question 15

A patient tells the nurse that he is upset because his surgical wound is infected,and everyone else that he knows who had the same surgery did not have the same problem.How should the nurse respond to this concern?

Accepted Answer

A) "There really is nothing that could be done to prevent it." 
B) "You should talk to your surgeon about your concerns." 
C) "At least you are in the hospital when the infection started and not at home." 
D) "Developing an infection depends on many factors,even things like age and gender."

Question 16

Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction?

Accepted Answer

A) 100 mg/dL 
B) 120 mg/dL 
C) 156 mg/dL 
D) 184 mg/dL

Question 17

The nurse would be most alert for the development of secondary pathway multiple organ dysfunction syndrome (MODS)in which patient?

Accepted Answer

A) A 40-year-old patient who went into neurologic shock following a fall 
B) A patient whose leg laceration was severely contaminated with soil from a rodeo arena 
C) A patient who has history of cirrhosis and diabetes who had chest injuries in an automobile accident 
D) A teenager who was bitten by a stray dog three days prior to admission

Question 18

A patient has developed multiple organ dysfunction syndrome (MODS).Which information should the nurse provide to the patient's family?

Accepted Answer

A) "Treatment will require intubation and placement on mechanical ventilation." 
B) "Treatment will focus on supporting all organ systems." 
C) "MODS can be corrected with antibiotic therapy and rest." 
D) "MODS patients require dialysis."

Question 19

The healthcare team is working to prevent the development of multiple organ dysfunction syndrome (MODS)in a critically injured patient.The nurse would evaluate that these efforts have failed when which findings develop?

Accepted Answer

A) Systemic inflammatory response syndrome (SIRS)is confirmed. 
B) Transfusion is required. 
C) Laboratory findings over the last 24 hours indicated renal failure. 
D) Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.

Question 20

The nurse will gather information about which organ system to figure a patient's Sequential Organ Failure Assessment (SOFA)score?

Accepted Answer

A) Integumentary 
B) Lymphatic 
C) Hematologic 
D) Endocrine

Exam 38: Multiple Organ Dysfunction Syndrome

A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F.What nursing intervention is priority?

A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis.The patient's wife says,"I thought he didn't have any infection." How should the nurse respond?

The nurse is caring for a patient with multiple organ dysfunction syndrome.Which interventions would help optimize tissue perfusion for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome (SIRS) .Which assessment findings would increase the patient's risk of developing this syndrome?

A hospitalized patient develops multiple organ dysfunction syndrome (MODS) .Which assessment findings would be the best indication of oxygenation status? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient is in the intensive care unit with multiple organ dysfunction syndrome.Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system?

A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome.Which laboratory results would confirm the nurse's suspicion of hepatic involvement?

A patient admitted with an infected wound is demonstrating signs of improvement.The nurse would attribute this improvement to which physiologic process?

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury.Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome (MODS) ?

A patient with a foot infection says,"I can hardly walk on my foot because it is stiff and swollen." What nursing response is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient has developed multiple organ dysfunction syndrome (MODS) .The nurse would monitor for development of which classic coagulation system findings?

A patient tells the nurse that he is upset because his surgical wound is infected,and everyone else that he knows who had the same surgery did not have the same problem.How should the nurse respond to this concern?

Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction?

The nurse would be most alert for the development of secondary pathway multiple organ dysfunction syndrome (MODS) in which patient?

A patient has developed multiple organ dysfunction syndrome (MODS) .Which information should the nurse provide to the patient's family?

The healthcare team is working to prevent the development of multiple organ dysfunction syndrome (MODS) in a critically injured patient.The nurse would evaluate that these efforts have failed when which findings develop?

The nurse will gather information about which organ system to figure a patient's Sequential Organ Failure Assessment (SOFA) score?