The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?

Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good

Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months

Promoting communication with the patient and family along with addressing end-of-life issues

Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

Answer and Explanation

The Correct Answer is C

Rationale:
A. Encouraging the family to stay hopeful and suggesting that the prognosis is good is incorrect because MODS carries a high mortality rate, especially when multiple organs are involved. Providing false reassurance is inappropriate and can damage trust.

B. Encouraging the family to leave the hospital and take time for themselves is incorrect because while self-care is important, family presence and involvement in care and decision-making are crucial, particularly in end-of-life or critical situations.

C. Promoting communication with the patient and family along with addressing end-of-life issues is correct because MODS is often progressive and life-threatening, and families benefit from honest communication, emotional support, and guidance in end-of-life decision-making. This approach respects patient and family needs and aligns care with their values and wishes.

D. Discussing organ donation on multiple occasions is incorrect because repeated discussions can be distressing and may not be appropriate until the patient’s prognosis is clear or death is imminent. Timing and sensitivity are critical when introducing organ donation.

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Correct Answer is D

Explanation

Rationale:
A. Administration of lactated Ringer's solution is incorrect because the patient is likely experiencing tension pneumothorax, not hypovolemic shock. Fluids alone will not relieve the life-threatening pressure in the pleural space.

B. Chest x-ray study is incorrect because tension pneumothorax is a clinical diagnosis and a medical emergency; waiting for imaging would delay life-saving treatment.

C. Endotracheal intubation and mechanical ventilation is incorrect because positive pressure ventilation can worsen a tension pneumothorax if the pleural pressure is not first relieved.

D. Needle thoracostomy and chest tube insertion is correct because the patient shows classic signs of tension pneumothorax: sudden hypotension, severe hypoxia, absent breath sounds on one side, and jugular venous distention. Immediate decompression with needle thoracostomy followed by chest tube placement is necessary to evacuate air, relieve pressure, and restore circulation and oxygenation.

A. Insert two 14-gauge IV catheters. B. Administer oxygen at 100% per non-rebreather mask. C. Place the patient on continuous cardiac monitor. D. Draw blood to type and crossmatch for transfusions.

Correct Answer is B

Explanation

Rationale:
A. Inserting two large-bore IV catheters is critical for rapid fluid resuscitation in a patient with hypovolemic shock, but ensuring adequate oxygenation takes absolute priority in the initial assessment. IV access should be established immediately after airway and oxygenation are addressed.
B. Administering oxygen at 100% via a non-rebreather mask is the first action because airway and oxygenation are the highest priorities in emergency care (following the ABCs: Airway, Breathing, Circulation). The patient’s cool, clammy skin, tachycardia, and hypotension indicate shock with potential tissue hypoxia, so supplemental oxygen is essential to improve oxygen delivery to vital organs.
C. Placing the patient on a continuous cardiac monitor is important for detecting arrhythmias and monitoring hemodynamic status, but it is not as urgent as securing oxygenation. Monitoring alone does not treat hypoxia.
D. Drawing blood for type and crossmatch is necessary for potential transfusions, but it is secondary to immediate interventions that ensure airway, oxygenation, and perfusion. Delaying oxygenation could result in rapid deterioration.

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The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Correct Answer is B

Explanation

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