SOLVED

 Question 11 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. Question 12 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 Question 13 The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient? 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 Question 14 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. Question 15 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? 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.” Question 16 A hospitalized patient develops multiple organ dysfunction syndrome. Which assessment findings would be the best indication of oxygenation status? 1. Absence of central cyanosis 2. Decreased bowel sounds 3. Unlabored respirations 4. Mental slowing 5. Normal pulse amplitude Question 17 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 Question 18 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. Question 19 Which information will the nurse gather to figure a patient’s Sequential Organ Failure Assessment (SOFA) score? 1. Hemoglobin 2. Blood glucose 3. Platelets 4. Urine pH Question 20 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.