SIRS and MODS

Question 1

The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with MODS. Which information must the nurse obtain before this measurement can be calculated? (select all that apply)

1. Heart rate
2. Central venous pressure
3. Mean arterial pressure
4. Temperature
5. PaFiO2

Answer 1

Correct Answer: 1,2,3

Rationale 1: Heart rate is a part of this calculation.

Rationale 2: Central venous pressure is used in this calculation.

Rationale 3: Mean arterial pressure is used in this calculation.

Rationale 4: Temperature is not part of this calculation.

Rationale 5: PaFiO2 is not part of this calculation.

Question 2

The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient? (select all that apply)

1. Assess pulse oximetry.
2. Maintain patency of the endotracheal tube.
3. Administer pain medications as scheduled.
4. Keep the environment calm and quiet.
5. Maintain a darkened environment

Answer 2

Correct Answer: 2,3,4

Rationale 1: Simply assessing pulse oximetry will not affect tissue perfusion but may provide information about gas exchange.

Rationale 2: Maintaining the integrity of the endotracheal tube is part of managing the care of a patient being mechanically ventilated. Mechanical ventilation helps to provide oxygen for perfusion.

Rationale 3: Managing pain helps to decrease oxygen consumption so that more oxygen is available for tissue perfusion.

Rationale 4: A calm environment decreases oxygen consumption.

Rationale 5: A darkened environment can be frightening and stressful for the patient which would increase oxygen consumption.

Question 3

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

1. Cover the patient with a warming blanket.
2. Communicate with the provider.
3. Increase frequency of turning and repositioning the patient.
4. Increase the amount of humidification given via the ventilator.

Answer 3

Correct Answer: 2

Rationale 1: The patient may be more comfortable with a warming blanket, but this is not the priority intervention.

Rationale 2: Communicating a low temperature to the provider and discussing alteration in the plan of care is an essential intervention.

Rationale 3: This intervention may be indicated, but is not the priority.

Rationale 4: Increasing the amount of humidification may be indicated, but this is not the priority intervention.

Question 3

A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, “I don’t think that nurse is being respectful of the patient’s diagnosis by telling jokes.” What response by the preceptor is indicated?

1. “When you have more experience you will understand the value of a good joke.”
2. “We try not to eavesdrop on other nurse’s conversations with patients.”
3. “Some times that nurse’s jokes do get old.”
4. “Sometimes laughing and joking can help us connect better with the patient.”

Answer 3

Correct Answer: 4

Rationale 1: The preceptor should discuss the value of humor without demeaning the newly licensed nurse’s level of experience.

Rationale 2: The preceptor should address the newly licensed nurse’s concerns as this is a teaching opportunity.

Rationale 3: The preceptor should not make any statements that could be interpreted as critical of the nurse since the preceptor is not aware of the nurse’s intent.

Rationale 4: The nurse and patient were engaging in humor. Humor can be used to lighten the moment and is associated with positive patient outcomes.

Question 3

A nurse questions why socioeconomic status has been included in the admission assessment form. What response by the nurse manager is most appropriate?

1. Socioeconomic status helps the business office determine the likelihood of receiving payment.
2. Socioeconomic status will provide helpful information in choosing a room and roommate for the patient.
3. Socioeconomic status may provide information about previous access to care.
4. Socioeconomic status will reveal the patient’s health care priorities.

Answer 3

Correct Answer: 3

Rationale 1: While the ability to manage hospital related costs might be impacted by the socioeconomic status it is not the primary reason for the assessment.

Rationale 2: Roommate selection is not the focus of this line of questioning.

Rationale 3: The socioeconomic status of a patient will provide information about the health care beliefs and access to health care.

Rationale 4: The patient’s socioeconomic status does not automatically determine health care priorities.

Question 4

A patient has decided to explore palliative care. After this decision is announced, the nurse notices that not all of the disciplines of the health care team seem to be supportive of the decision. What action by the nurse is indicated?

1. Contact the physician to report the discrepancies in the plan of care.
2. Discuss the patient’s wishes in the next multidisciplinary meeting.
3. Develop a plan of care and distribute it to the other disciplines of the health care team.
4. Advise the patient to contact the social services department.

Answer 4

Correct Answer: 2

Rationale 1: Calling the physician does not address the need for the differing disciplines to work together to benefit the patient.

Rationale 2: When a patient seeks palliative care, a multidisciplinary team should meet to formulate the plan of care.

Rationale 3: Distributing the plan of care without input from all of the participating fields will be ineffective and does little to promote collaboration.

Rationale 4: The social services department may be represented on the team but the patient does not have the responsibility to contact them.

Question 5

A nurse manager has recently held an educational program regarding palliative care for newly hired nurses on the high-acuity care unit. Which statement by a participant indicates the need for further education?

1. “The goals of medical care should be included in the palliative plan of care.”
2. “Advanced directives are not included in the palliative plan of care.”
3. “The plan of care should ensure the wishes of the patient at the time of death.”
4. “The palliative care plan should seek to ensure the patient and family understands the disease status.”

Answer 5

Correct Answer: 2

Rationale 1: Medical care goals are included in the palliative plan of care. The goals are no longer curative, but are focused on quality of life.

Rationale 2: Patient and family-centered decision making is a domain of palliative care. The nurse making this statement requires additional education.

Rationale 3: The focus of palliative care is that the patient’s wishes are honored.

Rationale 4: Education regarding the disease process is an essential part of the communication between caregiver and family.

Question 6

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. Which assessment findings would increase the patient’s risk of developing this syndrome?

1. Age 36
2. Body mass index of 23
3. Asian ancestry
4. 15 pack-year smoking history

Answer 6

Correct Answer: 4

Rationale 1: Patient-related risk factors for developing systemic inflammatory response syndrome include older age.

Rationale 2: A normal body mass index does not increase risk for SIRS.

Rationale 3: There is no indication that those of Asian ancestry are at higher risk of developing SIRS.

Rationale 4: Smoking is a risk factor for developing SIRS.

Question 6

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?

1. 100 mg/dL
2. 120 mg/dL
3. 156 mg/dL
4. 184 mg/dL

Answer 6

Correct Answer: 3

Rationale 1: The normal fasting blood sugar level is not a goal for this patient and may result in hypoglycemia.

Rationale 2: A high normal level of blood glucose is not the goal for this patient and may result in hypoglycemia.

Rationale 3: The goal for glucose control in this patient is approximately 150 mg/dL.

Rationale 4: This blood glucose level indicates inadequate glycemic control.

Question 6

A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurse’s arm demanding to know what is happening. Which initial nursing response is indicated?

1. “Your husband needs my full attention right now.”
2. “Someone call security.”
3. “Take your hands off of me.”
4. “Please go back to the waiting area.”

Answer 6

Correct Answer: 4

Rationale 1: The patient’s physiological needs take precedence over the psychological needs of the spouse.

Rationale 2: There is no indication that security is needed at this time.

Rationale 3: There is no indication that the nurse is in danger, so the therapeutic response should be directed toward the wife’s needs.

Rationale 4: Telling the wife to go back to the waiting room is not the best nursing response. She does have the right to information about her husband.

Question 7

A patient has developed MODS. The nurse would monitor for development of which classic coagulation system findings?

1. Large pulmonary emboli
2. Deep vein thrombosis
3. Clots in microcirculation
4. Clot occlusion of coronary arteries

Answer 7

Correct Answer: 3

Rationale 1: Large pulmonary emboli are not the most common effect of coagulation changes in MODS.

Rationale 2: Development of deep vein thrombosis is not the most common effect of coagulation changes in MODS.

Rationale 3: MODS causes abnormal clotting in the small blood vessels (microcirculation) that results in microthrombosis that obstructs blood flow.

Rationale 4: This is not the most common result of coagulation changes in MODS

Question 7

A patient has decided to forgo additional treatments for his terminal disease. The patient has presented a valid living will. The family is unhappy and tells the nurse they think the patient made the decision as a result of his depression. What response by the nurse is indicated?

1. “You need to let him make his own decisions.”
2. “Do you think if we talked to him he would change his mind?”
3. “My role is to assure your loved one’s wishes are followed.”
4. “You need to talk to his physician about revising the do not resuscitate order.”

Answer 7

Correct Answer: 3

Rationale 1: This statement is not the most therapeutic and does not address the family’s concern.

Rationale 2: To encourage the family to try to change the family member’s mind actually encourages them to pressure the patient at this serious time. This is not an action of a true patient advocate.

Rationale 3: The nurse must act as an advocate for the patient and uphold his documented requests.

Rationale 4: Referring the family to the physician to overturn the plans is not correct. A conference, however, may be indicated.

Question 8

The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated? (select all that apply)

1. “How long have you been in the United States?”
2. “How do you describe your ethnicity?”
3. “How does your culture influence your health care choices?”
4. “Do you speak English or do I need to try to find an interpreter?”
5. “Would you like for someone from your family to be in the room during your assessment?”

Answer 8

Correct Answer: 2,3,5

Rationale 1: This question is premature until the nurse determines if the patient was not born in the U.S.

Rationale 2: The nurse should base discussion of culture and ethnicity on the patient’s self-description.

Rationale 3: This is an open-ended question that allows the patient to either list some examples or to say there are no influences.

Rationale 4: This statement could be interpreted as indicating that accommodating language differences is a problem. The nurse should be able to assess for the need for an interpreter and should provide this service if necessary and possible.

Rationale 5: The nurse should ask about the desire for family presence. This is part of determining the patient’s support system.

Question 9

The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband’s continual denial of his disease. What should the nurse consider when planning a response to this concern?

1. It may be helpful for the patient’s emotional state at this time to be in a state of denial.
2. Denial is abnormal and the patient needs to have a consultation with a therapist.
3. It will be helpful to plan an intervention to force the patient to acknowledge his disease.
4. There is a limited amount of time left in the patient’s life so the denial must be rapidly worked through.

Answer 9

Correct Answer: 1

Rationale 1: It is believed that denial may be therapeutic as it allows the patient to have a removal from worry.

Rationale 2: Denial is a normal state experienced by patients having critical diagnoses.

Rationale 3: It is not therapeutic to force the patient to acknowledge his disease.

Rationale 4: Each patient will work through denial at an individualized pace. It is not therapeutic to rush this stage.

Question 10

Which interventions would the nurse use to help the patient get at least 2 hours of uninterrupted REM sleep?

1. Work with ancillary services such as physical therapy to establish a predictable routine.
2. Keep the lights in the unit dim at all times.
3. Turn alarms down or off during sleep periods.
4. Restrict visitation to a short time in the morning, the afternoon, and evening.

Answer 10

Correct Answer: 1

Rationale 1: If the nurse is aware of the routine times ancillary services will be provided, nursing care can be arranged to allow for the patient to have extended rest periods.

Rationale 2: The health care team must be able to see the patient well during assessment and care. Dimming the lights during portions of the day and night is indicated, but keeping the dim at all times in not possible.

Rationale 3: The nurse should never turn alarms off. Alarms must be loud enough to allow the nurse to hear them from areas outside the room.

Rationale 4: Strict visitation rules are not necessary, but the nurse might suggest visiting at another time if the patient is resting.

Question 11

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?

1. Increased flatus
2. Abdominal cramps
3. Absent bowel sounds
4. Complaint of epigastric burning

Answer 11

Correct Answer: 3

Rationale 1: Increased flatus would indicate some degree of gastrointestinal functioning.

Rationale 2: Abdominal cramps would indicate some degree of gastrointestinal functioning.

Rationale 3: Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the absence of normal bowel sounds.

Rationale 4: Complaint of epigastric burning is not specific to gastrointestinal dysfunction.

Question 12

A patient diagnosed with sepsis and multiple organ dysfunction syndrome has developed acute renal failure. Which arterial blood gas (ABG) result would the nurse expect to find?

1. pH = 7.30, PaCO2= 38, HCO3 = 16, PaO2 = 60
2. pH = 7.50, PaCO2 = 30, HCO3 = 26, PaO2 = 90
3. pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70
4. pH = 7.46, PaCO2 = 42, HCO3= 28, PaO2 = 80

Answer 12

Correct Answer: 1

Rationale 1: The choice pH = 7.30, PaCO2 = 38, HCO3 = 16, and PaO2 = 60 metabolic acidosis is correct because of anaerobic metabolism due to hypoxia and an increase in lactic acid and the kidney’s inability to excrete hydrogen ions. In acute renal failure metabolic acidosis can be caused by loss of bicarbonate.

Rationale 2: The choice pH = 7.50, PaCO2= 30, HCO3 = 26, PaO2 = 90 is incorrect because respiratory alkalosis can be found initially when a patient is hyperventilating or adjustments to the ventilator need to be made but not in an acute renal failure.

Rationale 3: The choice pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70 is incorrect; it is a normal ABG.

Rationale 4: The choice pH = 7.46, PaCO2 = 42, HCO3 = 28, PaO2 = 80 is incorrect because it is metabolic alkalosis and acute kidney failure would likely result in metabolic acidosis.

Question 13

A patient in Suchman’s awareness stage has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated?

1. The nurse should accept the behaviors and attempt to open the lines of communication.
2. Rotate the nursing assignments frequently to limit each nurse’s exposure to the behaviors.
3. Confront the patient about his demeanor.
4. Consolidate care so the nurse is in the room for shorter periods.

Answer 13

Correct Answer: 1

Rationale 1: The patient is acting in a manner consistent with the stage of awareness. The patient is attempting to exert control over the situation and will benefit most from a supportive environment.

Rationale 2: Rotating nursing assignments interrupts the therapeutic environment this patient requires.

Rationale 3: Confrontation is not indicated at this time. The patient needs to move through this stage of illness with support and understanding.

Rationale 4: This patient needs support to work through these feelings. Reducing the amount of time the nurse is in the room does not allow for interactions that may help with this process

Question 14

A newly licensed nurse says, “Every time I go into my trauma patient’s room his wife asks the same questions about his medication.” How should the preceptor evaluate this statement?

1. Anxiety about the husband’s condition has affected the wife’s ability to retain information.
2. The preceptor should present the information so that it is more understandable.
3. When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family.
4. The nurse and wife are not communicating well with one another.

Answer 14

Correct Answer: 1

Rationale 1: When faced with serious illness or injury, patients and their families are stressed and may have problems retaining information presented.

Rationale 2: There is no indication that the nurse did not present the information well.

Rationale 3: The nurse should talk to the patient, so this is not a mistake. The information should be directed to the patient and the family.

Rationale 4: There is no indication that the nurse is not attempting communication with the wife.

Question 15

A patient says, “I’ve been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it?” Which nursing responses are indicated? (select all that apply)

1. “Some studies have shown that using lavender oil can reduce anxiety.”
2. “I would focus my energy on more traditional forms of healing.”
3. “Other than jasmine oil, you are probably safe using aromatherapy.”
4. “You should discuss this plan with your physician before purchasing anything.”
5. “I know that some massage therapists use essential oils.”

Answer 15

Correct Answer: 1,5

Rationale 1: Some small, limited studies have shown lavender oil to reduce stress and anxiety in acutely ill patients.

Rationale 2: Some studies have shown that some oils do help to reduce stress and anxiety in acutely ill patients. The nurse should not devalue this patient’s attempts at self-help.

Rationale 3: Jasmine oil has been shown, in small studies, to reduce stress and anxiety in acutely ill patients.

Rationale 4: The nurse should be able to discuss this topic with the patient.

Rationale 5: These oils may be inhaled or used as an enhancement to massage therapy.

Question 16

The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, “I would rather talk to my usual nurse about my discharge.” What action by the nurse is indicated?

1. Ask the patient to sign a refusal of information form.
2. Continue to provide the information to the patient.
3. Ask the patient what efforts could be taken to make him feel more comfortable.
4. Contact the health care provider.

Answer 16

Correct Answer: 3

Rationale 1: The nurse is responsible to attempt education of this patient and would not simply ask the patient to sign a refusal form.

Rationale 2: Forcing the information on the patient would be counterproductive and cause more anxiety.

Rationale 3: The patient is not feeling secure. Acutely ill patients need to feel comfortable and secure in order to learn.

Rationale 4: There is no reason to contact the health care provider.

Question 17

The family of a critically ill patient reports to the nurse concerns that none of the health care team members seem to be listening to their wishes. Which nursing response is indicted?

1. “You have to stand up for yourself and for your loved one.”
2. “It is time for us to meet in a patient care conference.”
3. “I will talk to the hospital administrator about your complaint.”
4. “I know this whole thing has been very hard on your family.”

Answer 17

Correct Answer: 2

Rationale 1: The family is in a time of crisis and should not be required to “stand up” for themselves and the patient.

Rationale 2: A patient care conference is indicated to ensure that all members of the health care team are communicating actions.

Rationale 3: The nurse should not characterize this report as a complaint; it is a statement of the facts as they are perceived by the family. There is no reason to contact the administrator as steps to correct this problem can begin at the unit level.

Rationale 4: Offering emotional support is important but does not address the root cause of the problems being perceived by the family.

Question 18

A patient who underwent transurethral resection of the prostate 5 days ago returns to the emergency department. After assessing the patient and obtaining laboratory results the nurse notes a temperature of 96.8°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3,000 mm3. The nurse anticipates additional treatment for which disorder?

1. Systemic inflammatory response syndrome
2. Homeostasis
3. Localized inflammation
4. Multiple organ dysfunction syndrome

Answer 18

Correct Answer: 1

Rationale 1: Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4,000/mm3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis.

Rationale 2: Homeostasis is incorrect because the clinical manifestations are not compatible with the state of equilibrium found in homeostasis.

Rationale 3: Localized inflammation may exist and contribute to the patient’s condition, but is not the specific problem of concern.

Rationale 4: There is no indication of the failure of organ systems.

Question 19

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?

1. Urine output less than 400 mL/day
2. Decreased PaO2 with an increase in FiO2
3. Alteration in level of consciousness
4. Hypotension that responds to fluids

Answer 19

Correct Answer: 2

Rationale 1: Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome.

Rationale 2: Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome.

Rationale 3: Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome.

Rationale 4: The hypotension and dysrhythmias common in MODS do not respond to fluid therapy.

Question 20

The charge nurse on a busy high-acuity care unit is reviewing the plan of care for four patients. The nurse would evaluate that which patient is at highest risk for sensory perceptual alterations (SPAs)? 1. 52-year-old male patient who has been hospitalized for complications related to diabetes 2. 41-year-old female patient admitted with severe abdominal pain 3. 65-year-old male patient diagnosed with pulmonary embolism. 4. 79-year-old female patient who is unresponsive after a stroke

Answer 20

Correct Answer: 4 Rationale 1: The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the patient’s diagnosis does not put him at highest risk in this group. Rationale 2: The patient is at risk for SPAs because of being cared for on a high-acuity unit. However the diagnosis and age do not put her at highest risk in this group. Rationale 3: This patient is at risk for SPAs because of being cared for on a high-acuity unit. However this diagnosis does not put him at highest risk in this group. Rationale 4: Patients who are very young, very old, and postoperative or unresponsive are at the greatest risk for experiencing sensory perceptual alterations (SPAs). The 79-year-old patient is at the greatest risk as a result of age and diagnosis.

Question 21

The wife of a critically ill patient asks the nurse for help in making end-of-life care decisions for her husband. What action by the nurse is indicated? 1. Encourage the wife to recall any discussions with her husband about his wishes. 2. Encourage the wife to discontinue aggressive medical treatments as soon as possible. 3. Tell the wife what most other families have done in similar situations in the past 4. Refer the wife to social services for information about end of life.

Answer 21

Correct Answer: 1 Rationale 1: The nurse should refer to the patient’s wishes as being of utmost importance. Rationale 2: The nurse should not offer advice about end-of-life decisions, but rather should offer information. Rationale 3: The actions taken by other families are not pertinent to this family. Rationale 4: The nurse should be prepared to discuss end-of-life issues with the family. Referral to social services is not necessary for this discussion.

Question 23

A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made his arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort? (select all that apply) 1. Aromatherapy 2. Therapeutic humor 3. Massage 4. Guided imagery 5. Music therapy

Answer 23

Correct Answer: 1,2,4,5 Rationale 1: The scents of lavender and jasmine have been shown in some studies to help reduce stress and anxiety. Rationale 2: Watching comedies on television or reading humorous books may help distract the patient from discomfort. Rationale 3: Because this patient is being treated for deep vein thrombosis, massage is not indicated. Rationale 4: Guided imagery may help the patient relax. Rationale 5: Music may help distract the patient from discomfort. Music can also be calming.

Question 24

A hospitalized patient develops multiple organ dysfunction syndrome. Which assessment findings would be the best indication of oxygenation status? (select all that apply) 1. Absence of central cyanosis 2. Decreased bowel sounds 3. Unlabored respirations 4. Mental slowing 5. Normal pulse amplitude

Answer 24

Correct Answer: 2,4 Rationale 1: Patients with MODS may appear clinically to have adequate oxygenation. It is not possible to determine that the patient is oxygenating all tissues on the basis of absence of central cyanosis. Rationale 2: Regional tissue hypoxia, particularly in the intestinal tract, is a complication of MODS. Decreased bowel motility, evidenced by decrease in bowel sounds, is a result of that hypoxia. Rationale 3: The patient with MODS may appear clinically to have adequate oxygenation, so respiratory effort may also appear to be normal. Rationale 4: Regional tissue hypoxia occurs in MODS, particularly in the brain. Slowing of mental processes results from that hypoxia. Rationale 5: Increasing cardiac contractility is compensatory for decreased tissue perfusion. This change will result in normal pulse amplitude in many cases, so the presence of normal pulses does not rule out regional tissue hypoxia.

Question 25

The nurse has been assigned to care for a patient who is unresponsive. The patient has no living will and the family has requested no resuscitative measures be implemented. No “do not resuscitate” order has been written and the nurse feels confident that life saving measures would likely be successful if implemented. What action by the nurse is indicated if this patient suffers a cardiopulmonary arrest? 1. Begin resuscitation interventions. 2. Discuss the situation with the unit manager. 3. Contact the hospital attorney. 4. Tell the family that resuscitation efforts are indicated and would likely be successful.

Answer 25

Correct Answer: 1 Rationale 1: Since there is no living will, the nurse must begin resuscitation interventions if indicated. Rationale 2: Discussing the situation with the unit manager does not relieve the nurse of the responsibility of attempting resuscitation. At the time of need for resuscitation it is too late to discuss an action plan with the unit manager. Rationale 3: It would be inappropriate for the nurse to contact the hospital attorney. Rationale 4: The nurse should not share these beliefs with the family.

Question 27

Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction in a critically ill patient who is being mechanically ventilated? 1. Enforcing hand washing before and after touching a patient 2. Following an evidence-based ventilator bundle 3. Using urinary catheters to prevent perineal skin breakdown 4. Complying with turning and repositioning schedules 5. Restricting visitors to immediate family only

Answer 27

Correct Answer: 1,2,4 Rationale 1: Enforcing hand washing before and after touching a patient is correct because hand washing may prevent infections. Rationale 2: An evidence-based ventilator bundle should be implemented to help avoid ventilator-associated pneumonias. Rationale 3: Use of urinary catheters increases risk for infection and risk for multiple organ dysfunction. Rationale 4: Minimizing the risk for pressure ulcers by relieving pressure and shear points can help prevent development of MODS. Rationale 5: Restricting visitors is not necessary as long as universal precautions are followed.

Question 29

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? 1. Increased fibrinogen level 2. Decreased blood urea nitrogen 3. Increased serum bilirubin 4. Increased serum albumin

Answer 29

Correct Answer: 3 Rationale 1: Abnormalities in the liver would be likely to result in decreased fibrinogen levels. Rationale 2: Blood urea nitrogen changes for several reasons and would generally increase in metabolic disorders. Rationale 3: Liver dysfunction typically manifests as high levels of serum bilirubin. An increased serum bilirubin level would confirm the suspicion of hepatic involvement. Rationale 4: Low serum albumin levels would indicate liver involvement.

Question 30

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? 1. He probably had an infection that we did not recognize. 2. He developed SIRS after getting MODS. 3. Infection isn’t necessary to develop SIRS, only a severe inflammation. 4. Your husband’s body is working against itself.

Answer 30

Correct Answer: 3 Rationale 1: SIRS can occur in the absence of infection. Rationale 2: Multiple organ dysfunction syndrome follows SIRS. Rationale 3: Pancreatitis is a severe inflammatory illness. SIRS can develop without infection. Rationale 4: The wife is not likely to understand this explanation

Question 31

The nurse manager is planning an educational program to address noise levels on the unit. What information should be given about the recommended noise levels? (select all that apply) 1. It is recommended that noise levels in the hospital should be below 45 dBA during daytime hours. 2. Normal conversation exceeds the recommended daytime noise level. 3. At night it should be quieter, no more than 35 dBA are recommended. 4. The recommended noise levels in high-acuity areas are higher due to increase noise from alarms and machines. 5. The biggest patient complaint about noise is in regard to staff conversation.

Answer 31

Correct Answer: 1,2,3,5 Rationale 1: The Environmental Protection Agency recommends hospitals maintain noise levels of 45 dBA during the day. Rationale 2: Normal conversation is around 60 dBA, which exceeds the recommended daytime level in the hospital. Rationale 3: The Environmental Protection Agency recommends that hospitals maintain noise levels no higher than 35 dBA at night. Rationale 4: The Environmental Protection Agency has set levels for hospitals in general. Rationale 5: Patients complain that staff conversations wake them from sleep.

Question 32

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? 1. “There really is nothing that could be done to prevent it.” 2. “You should talk to your surgeon about your concerns.” 3. “At least you are in the hospital when the infection started and not at home.” 4. “Developing an infection depends on many factors, even things like age and gender.”

Answer 32

Correct Answer: 4 Rationale 1: The nurse has no way of knowing if there was a way to prevent this patient’s infection. Rationale 2: The nurse can offer some explanation about the development of infection instead of referring the patient to the surgeon. Rationale 3: Commenting about being in the hospital instead of home when the infection developed does not address the patient’s concerns. Rationale 4: How endothelial cells respond to alterations in the environment differ, according to the host genetics, age, gender, nature of the pathogen, and location of the vascular bed. The nurse should explain to the patient that the development of a wound infection depends upon these variables.

Question 33

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? (select all that apply) 1. “Infections in the foot always swell because of gravity.” 2. “The swelling and pain help remind you not to overuse your foot.” 3. “That is a sign of infection that would not have occurred if the area was only inflamed.” 4. “Swelling indicates that your infection is getting worse.” 5. “Inflammation often causes pain and tissue swelling.”

Answer 33

Correct Answer: 2,5 Rationale 1: The swelling is a normal part of the inflammatory process. Rationale 2: Loss of function due to local swelling and pain is a physiologic change to help protect the site of injury. Rationale 3: Inflammation also results in localized swelling and pain. Rationale 4: Swelling may or may not indicate worsening of the infection. Rationale 5: Pain and swelling are normal parts of the inflammatory response.

Question 34

The health care team is working to prevent the development of MODS in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop? 1. SIRS is confirmed. 2. Transfusion is required. 3. Laboratory findings over the last 24 hours indicated renal failure. 4. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.

Answer 34

Correct Answer: 4 Rationale 1: SIRS is a risk factor, but not all persons with SIRS develop MODS. Rationale 2: Transfusion is a risk factor, but not all those who receive transfusions develop MODS. Rationale 3: Failure of one organ system does not indicate MODS. Rationale 4: MODS is the failure of two or more organ systems that persists beyond 24 hours.

Question 35

A patient has developed MODS. Which information should the nurse provide to the patient’s family? 1. Treatment will require intubation and placement on mechanical ventilation. 2. Treatment will focus on supporting all organ systems. 3. MODS can be corrected with antibiotic therapy and rest. 4. MODS patients require dialysis.

Answer 35

Correct Answer: 2 Rationale 1: Not all MODS patients require this level of respiratory support. Rationale 2: Treatment must focus on supporting those organ systems that are failing and protecting the organ systems that have not failed. Rationale 3: There is no definitive treatment for MODS. Rationale 4: Not all patients require this level of renal support.

Question 36

A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process? 1. Cortisol released from the adrenal glands 2. Hypothalamus activating white blood cells 3. Endothelial cells releasing mediators to contain the infection 4. Mediators that decrease permeability of vessel walls

Answer 36

Correct Answer: 3 Rationale 1: The wound infection was not contained because of the release of cortisol by the adrenal glands. Rationale 2: The hypothalamus does not activate white blood cells. Rationale 3: Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection. Rationale 4: Permeability of the vessel walls is increased in order to contain infection.