NCLEX Review Questions (Wagner) - Chapter (37)

Chapter 37: Multiple Organ Dysfunction Syndrome NCLEX® Review This activity contains 10 questions. A patient has signs of inflammation around a laceration. If the patient's inflammatory response is normal, what will occur? Select all that apply. The inflammation will stay in the local area. The inflammation will be cleared systemically. Healing will be promoted. Systemic vasomotor tone will be altered. The extent of the injury will be limited. A patient sustained a deep laceration. Which assessment findings would the nurse interpret as indicating a normal inflammatory response? Select all that apply. Patient reluctance to use the extremity Pain Coolness of skin around the laceration site Redness directly around the laceration Slight swelling at the incision site A patient has been diagnosed with SIRS. How should the nurse interpret this information? A localized inflammatory response is occurring. Generalized activation of inflammation and coagulation is occurring. The endothelium is shutting down. Tightly regulated inflammatory responses are occurring in multiple body sites. Which patient would the nurse monitor most closely for the development of SIRS? A patient who just had surgery A patient injured in a fall A patient who sustained burns A patient who is septic A patient who developed MODS has five dysfunctional organ systems. What nursing intervention is indicated? Tell the patient's family that he is making progress towards returning to his previous health. Advise the patient's family to make arrangements for home care for at least the first few weeks after the patient returns home. Plan gradual return to ambulation. Begin to prepare the family for the patient's demise. A patient who suffered crushing injuries to her legs has now developed SIRS. Which organ systems should the nurse monitor most closely for failure due to their vulnerability to distant organ injury? Select all that apply. Urinary system Respiratory system Hepatic system Neurologic system Cardiovascular system Calculate the SOFA score for a patient with a PaO2/FiO2 of 98 when on mechanical ventilation, platelets 18 x 109/L, bilirubin 12.5 mg/dL, MAP less than 70 mm Hg on norepinephrine 0.2 mcg/kg/min., GSC 5, creatinine 5.0 mg/dL, and urine output 198 mL/day. 29 7 17 45 A patient with MODS has been averaging about 300-325 mL of urine output each day. Yesterday and today, the patient's output has risen to 500 and 560 mL, respectively. How should the nurse interpret this finding? Creatinine levels should be obtained. This patient is at greater risk of death than when output was lower. There is no logical interpretation of this information. This patient's mortality risk is lower than when output was lower. The unit nurse educator is working to reduce the number of unit patients who develop SIRS from sepsis. What education should this nurse provide to staff? Select all that apply. "Advocate for all patients to be on broad-spectrum antibiotics." "Perform hand hygiene often and according to policy and procedures." "Follow procedures for the care of central lines." "Institute meticulous skin care regimens for all patients." "Use ventilator bundle interventions for patients on mechanical ventilation." Which intervention should the nurse implement to reduce oxygen consumption in a patient diagnosed with MODS? Promote an atmosphere of calm and quiet within the nursing unit. Keep the patient flat in bed. Reduce visitors to immediate family for 2 hours each day. Group all nursing interventions at the beginning of the shift.