ICU Care: Nursing Priority in MODS
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Questions and Answers

What is a characteristic of sudden loss of consciousness?

  • Hot, dry skin
  • Diminished or absent breath sounds on the affected side
  • Muffled heart sounds
  • Paradoxical chest wall movement with respirations (correct)
  • What should be the priority nursing action for a patient with multiple organ dysfunction syndrome (MODS) due to shock?

  • Prepare the family for a long recovery process
  • Provide the family with clear information and emotional support (correct)
  • Educate the patient and family about the treatment plan
  • Plan for rehabilitation phase
  • What symptom would indicate the need to take a form of glucose in a patient with diabetes mellitus?

  • Diaphoresis (correct)
  • Fruity breath odor
  • Polyuria
  • Hot, dry skin
  • What is the purpose of asking 'what time was the patient last fully functional' in a patient with acute onset of facial drooping and slurred speech?

    <p>To determine the course of treatment for an ischemic stroke</p> Signup and view all the answers

    What is the primary purpose of an escharotomy?

    <p>To relieve pressure and promote circulation</p> Signup and view all the answers

    What is a sign of respiratory distress?

    <p>Paradoxical chest wall movement with respirations</p> Signup and view all the answers

    What is a priority nursing action for a patient with multiple organ dysfunction syndrome (MODS)?

    <p>Focusing on stabilizing the patient's hemodynamic status</p> Signup and view all the answers

    What is a characteristic of cardiac tamponade?

    <p>Muffled heart sounds</p> Signup and view all the answers

    What is the correct way to remove dead tissue from a burned area?

    <p>Placing the patient in a shower and removing the dead tissue</p> Signup and view all the answers

    What is the infusion rate in ml/hr that the nurse should set for the gentamycin dose?

    <p>200 ml/hr</p> Signup and view all the answers

    Which patient statement indicates that the nurse's nutritional teaching plan has been effective for a low-sodium diet?

    <p>I will have a baked potato with broiled chicken for dinner</p> Signup and view all the answers

    What is a common initial symptom of HIV infection?

    <p>Flu-like symptoms</p> Signup and view all the answers

    What should the nurse do before applying new wound dressings to a patient with burns on their upper thighs and knees?

    <p>Assess the patient's peripheral pulses distal to the dressing</p> Signup and view all the answers

    What is the purpose of making large incisions in the eschar of a burned patient?

    <p>To improve circulation</p> Signup and view all the answers

    What is the goal of a low-sodium diet for a patient with heart failure?

    <p>To reduce fluid retention</p> Signup and view all the answers

    What is the primary focus of postoperative care for a burned patient?

    <p>Preventing infection</p> Signup and view all the answers

    Which of the following is NOT part of the primary survey when initially assessing a patient in the emergency room?

    <p>Cleansing a wound on lower extremity</p> Signup and view all the answers

    Which patient has the LEAST risk of developing acute respiratory distress syndrome (ARDS)?

    <p>50-year-old adult seasonal allergies</p> Signup and view all the answers

    Why may a patient with hemorrhagic stroke not receive clot-busting medication (tPA)?

    <p>The medication could cause more bleeding.</p> Signup and view all the answers

    What is a common complication of modified radical mastectomy?

    <p>Lymphedema</p> Signup and view all the answers

    What does constant tiddling in the water-seal chamber of a closed chest-drainage system indicate?

    <p>The system is functioning normally.</p> Signup and view all the answers

    What is a common site of metastasis for cancer cells?

    <p>Liver</p> Signup and view all the answers

    Why should blood pressure be obtained from the unaffected arm in a client undergoing mastectomy?

    <p>To prevent lymphedema.</p> Signup and view all the answers

    What is the primary goal of elevating the affected arm and hand in a client undergoing mastectomy?

    <p>To prevent lymphedema.</p> Signup and view all the answers

    Study Notes

    Sudden Loss of Consciousness

    • Muffled heart sounds
    • Paradoxical chest wall movement with respirations
    • Diminished or absent breath sounds on the affected side

    Nursing Priorities

    • Providing clear information and emotional support to the family of a patient with multiple organ dysfunction syndrome (MODS) due to shock

    Diabetes Mellitus

    • Diaphoresis, palpitations, and shakiness are symptoms of hypoglycemia
    • Hot, dry skin, polyuria, and fruity breath odor are symptoms of hyperglycemia

    Acute Onset of Facial Drooping and Slurred Speech

    • Assessing the time the patient was last fully functional is important in determining the prognosis of a hemorrhagic stroke

    Escharotomy

    • Large incisions are made in the eschar to improve circulation

    Medication Administration

    • To administer 1mg/kg of gentamycin IV 8h, the nurse would set the infusion pump at 200ml/hr for a 90kg patient

    Heart Failure

    • A low-sodium diet is recommended for patients with heart failure
    • Avoiding ham and cheese sandwiches, salads with cheese and croutons, and chicken noodle soup with crackers is important

    HIV and AIDS

    • Flu-like symptoms are initial manifestations of HIV infection

    Burn Care

    • Assessing peripheral pulses distal to the dressing and administering PRN analgesia as ordered are important nursing actions before applying new wound dressings
    • Instructing the patient to keep the wound site in a dependent position and assisting with passive range of motion exercises are also important

    Primary Survey

    • Assessing breathing, level of consciousness, and circulatory status by checking pulse and blood pressure are part of the primary survey

    Acute Respiratory Distress Syndrome (ARDS)

    • A 70-year-old adult who is septic has the greatest risk of developing ARDS

    Hemorrhagic Stroke

    • Clot-busting medication (tPA) may not be administered due to the risk of causing more bleeding

    Cancer

    • The liver is one of the most common metastasis sites for cancer cells

    Breast Cancer

    • Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent lymphedema

    Closed Chest-Drainage System

    • Constant tiddling in the water-seal chamber indicates that the system is functioning normally

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    Related Documents

    Adult Health 2 Final Exam PDF

    Description

    This quiz focuses on the nursing priority in caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock in an ICU setting.

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