A client with tumor lysis syndrome is being managed in the emergency department.
Which nursing intervention should the nurse implement to prevent acute kidney injury?
Encourage fluid intake of 3 liters daily.
Place the client in a semi-Fowler's position.
Obtain blood cultures.
Administer high-dose intravenous corticosteroids.
Administer high-dose intravenous corticosteroids.
The Correct Answer is A
Choice A rationale
Tumor lysis syndrome is an oncologic emergency characterized by the rapid release of intracellular contents, including potassium, phosphate, and nucleic acids, into the bloodstream. These nucleic acids are metabolized into uric acid, which can precipitate in the renal tubules, leading to obstructive uropathy and acute kidney injury. Aggressive hydration, typically 3 liters or more daily, is the primary intervention to increase urine flow, dilute the concentration of these substances, and promote their renal excretion.
Choice B rationale
The semi-Fowler's position is primarily utilized to improve lung expansion and decrease the work of breathing in patients with respiratory distress or to prevent aspiration. While comfortable, it does not directly address the underlying pathophysiology of tumor lysis syndrome or the prevention of acute kidney injury. The priority in this metabolic emergency is maintaining high intravascular volume and renal perfusion to clear the excessive load of electrolytes and uric acid produced by the rapidly lysing malignant cells.
Choice C rationale
Obtaining blood cultures is a standard intervention for suspected sepsis or systemic infection but is not a primary treatment for tumor lysis syndrome. While oncology patients are often immunocompromised and at risk for infection, the immediate threat in tumor lysis syndrome is metabolic derangement and renal failure. Nurses should focus on monitoring electrolyte levels, such as potassium (normal 3.5 to 5.0 mEq/L) and phosphorus (normal 2.5 to 4.5 mg/dL), and ensuring aggressive fluid resuscitation rather than diagnostic tests for infection.
Choice D rationale
High-dose intravenous corticosteroids are not the standard treatment for preventing acute kidney injury in the context of tumor lysis syndrome. While steroids may be part of the chemotherapy regimen that initially triggered the cell lysis, the management of the resulting syndrome involves hydration, allopurinol or rasburicase to lower uric acid levels, and the management of electrolyte imbalances. Corticosteroids do not assist in the clearance of uric acid or the protection of renal tubules from metabolic crystalline deposits. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering chemotherapy involves the handling of highly toxic cytotoxic agents that require specialized certification and advanced clinical knowledge. Nursing assistants do not possess the legal scope of practice or the pharmacological training to manage these medications, even under direct supervision. Prioritizing this delegation would violate safety protocols and state nurse practice acts, as the risk of extravasation or systemic toxicity requires continuous assessment by a registered nurse.
Choice B rationale
Monitoring vital signs is a technical task that falls within the competency of a nursing student who has received proper instruction. The registered nurse remains responsible for interpreting these values, but delegating the collection of data allows for efficient workflow. Vital signs provide critical data on the hemodynamic stability of a cancer patient, and a qualified student can accurately perform this task once they have demonstrated clinical proficiency in a controlled environment.
Choice C rationale
Patient education regarding the complex side effects of radiation therapy is a core responsibility of the registered nurse that cannot be delegated to a licensed practical nurse. Radiation involves intricate physiological changes, such as skin integrity breakdown and internal tissue inflammation, requiring a high level of clinical judgment. While an LPN can reinforce teaching, the initial assessment of learning needs and the development of the educational plan must be performed by the professional nurse.
Choice D rationale
Performing clinical assessments is a non-delegable task that requires professional diagnostic reasoning and specialized medical knowledge. Family members can provide subjective information regarding a patient's comfort or history, but they lack the objective clinical training required to evaluate physical symptoms or disease progression. Assigning assessment tasks to unlicensed individuals who are not healthcare professionals compromises patient safety and leads to inaccurate data collection regarding the patient's oncological status.
Correct Answer is ["A","B","C","F"]
Explanation
Choice A rationale
Chronic conditions such as cardiovascular disease or diabetes mellitus can significantly impair the body's ability to circulate blood to the skin for heat dissipation. Furthermore, specific medications including diuretics, antihistamines, and beta-blockers interfere with sweating mechanisms or cardiac output. This disruption in homeostatic thermoregulation prevents the hypothalamus from effectively lowering the core body temperature during periods of high thermal stress, thereby increasing the clinical susceptibility to heat-related illnesses.
Choice B rationale
Aging is associated with physiological changes that decrease the efficiency of the thermoregulatory system, including a reduced number of active sweat glands and decreased dermal blood flow. The loss of subcutaneous fat in older adults may paradoxically impair the body's insulation and its ability to regulate temperature fluctuations. Consequently, the elderly population cannot dissipate heat as rapidly as younger individuals, which raises the risk of progressing from heat exhaustion to life-threatening heat stroke.
Choice C rationale
Dehydration significantly reduces the total circulating blood volume, which is essential for transporting heat from the internal organs to the skin surface. When fluid intake is insufficient, the body prioritizes maintaining blood pressure over thermoregulation, leading to a cessation of sweating to conserve water. Without the evaporative cooling provided by sweat, the core body temperature rises uncontrollably. Normal adult fluid requirements are approximately 2000 to 3000 mL daily to maintain adequate hydration.
Choice D rationale
Performing regular physical activity within a moderate, climate-controlled environment does not typically pose a significant threat to the body's thermoregulatory capacity. In these conditions, the ambient temperature gradient allows for efficient heat loss through radiation and convection. Since the environmental stress is low, the physiological mechanisms for cooling remain functional and are not overwhelmed. Therefore, this factor does not contribute to the onset of heat exhaustion or heat stroke in most healthy or stable patients.
Choice E rationale
A sedentary lifestyle in a cold environment is generally associated with risks related to hypothermia or frostbite rather than heat-related emergencies. Heat stroke requires high external temperatures or extreme internal metabolic heat production that exceeds the body's ability to cool itself. Cold exposure causes peripheral vasoconstriction to conserve heat, which is the opposite physiological process of what occurs during heat exhaustion. Consequently, these specific conditions do not facilitate the development of hyperthermic syndromes.
Choice F rationale
High ambient temperatures combined with elevated humidity create a dangerous environment because the air is saturated with moisture, preventing the evaporation of sweat. Evaporation is the primary mechanism for heat loss in humans when the environment is warmer than the skin. When sweat cannot evaporate, the body's most effective cooling tool is neutralized. This leads to a rapid accumulation of metabolic and environmental heat within the tissues, causing systemic cellular dysfunction and potential multi-organ failure.
Choice G rationale
Wearing loose-fitting and lightweight clothing is a protective measure rather than a risk factor. Such attire allows for maximum airflow over the skin surface, which facilitates the evaporation of perspiration and the convective loss of heat. Tight or heavy clothing traps heat and moisture against the body, creating a microenvironment that hinders cooling. By promoting ventilation, lightweight clothing assists the body in maintaining a stable internal temperature even when exposed to moderately high external heat.
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