A patient diagnosed with Acute Kidney Injury (AKI) secondary to SIRS, at risk of progressing to Multi-Organ Dysfunction Syndrome (MODS) is admitted for treatment. The susceptibility to nephrotoxic effects necessitates vigilant nursing care.
Which nursing intervention is essential in preventing additional kidney damage in this patient?
Increase the frequency of vital signs monitoring to detect SIRS-related changes.
Carefully monitor and document the patient's serum drug levels to avoid toxicity.
Administer nephrotoxic medications early in the day to facilitate drug clearance.
Prioritize nutritional support
The Correct Answer is B
A. Increase the frequency of vital signs monitoring to detect SIRS-related changes:
This is important for systemic assessment but does not directly protect the kidneys from further injury.
B. Carefully monitor and document the patient's serum drug levels to avoid toxicity:
The kidneys excrete many medications. In AKI, impaired clearance increases the risk of drug accumulation and toxicity, making drug level monitoring critical.
C. Administer nephrotoxic medications early in the day to facilitate drug clearance:
Timing does not reduce nephrotoxicity. The type and dosage of drug, along with renal function, are more important considerations.
D. Prioritize nutritional support:
While essential for healing, nutrition does not directly prevent nephrotoxicity. Renal-safe feeding is needed, but drug monitoring is the priority for kidney protection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Contact the donor network and allow them to initiate the conversation with the family:
This is the standard protocol. Only trained organ procurement organization (OPO) staff should initiate organ donation discussions to ensure the family receives accurate and compassionate guidance.
B. Provide the family with organ donation pamphlets and leave the decision to them:
Providing materials may be part of the process after OPO involvement, but initiating this conversation is not within the nurse’s role.
C. Discuss organ donation with the family clergy if present:
Clergy may be involved for spiritual support, but they do not initiate medical discussions about organ donation.
D. Discuss organ donation options directly with the family:
The nurse should not directly initiate organ donation discussions. This must be done by the OPO or donor network, per national regulations and hospital policy.
Correct Answer is B
Explanation
A. MODS can be diagnosed when one organ system fails for more than 24 hours:
This describes single organ failure, not MODS.
B. MODS is the failure of 2 or more organ systems in an acutely ill patient:
This is the correct definition of MODS. It is a progressive, life-threatening condition often resulting from sepsis, trauma, or shock.
C. MODS is the sequential failure of organ systems in a healthy individual:
MODS develops in critically ill patients, not healthy individuals, typically due to an overwhelming insult like infection or trauma.
D. MODS is the failure of a single organ system due to chronic illness:
Chronic organ failure is not MODS. MODS is acute and involves multiple organs.
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