Introduction Critical Care Nursing 7th Edition By Sole Klein – Test Bank

Chapter 11: Organ Donation
Sole: Introduction to Critical Care Nursing, 7th Edition

MULTIPLE CHOICE

1. The nurse is caring for a patient who has a Glasgow Coma Scale (GCS) score of 3. Discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?
a. “I need to notify the local Organ Procurement Organization of my patient’s im-pending death.”
b. “I will contact the provider to obtain informed consent for organ donation.”
c. “The charge nurse will notify the local Organ Procurement Organization once the patient has been pronounced brain dead.”
d. “I need the physician to evaluate my patient’s suitability for organ donation.”

ANS: A
Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the provider, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur before death, not after the patient has been pronounced dead.

DIF: Cognitive Level: Understand/Comprehension REF: p. 233
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

2. The nurse is managing a donor patient six hours before the scheduled har-vesting of the patient’s organs. Which assessment finding requires immediate action by the nurse?
a. Morning serum blood glucose of 128 mg/dL
b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L
c. Pulmonary artery temperature of 97.8° F
d. Central venous pressure of 8 mm Hg

ANS: B
Donor management focuses on maintaining hemodynamic stability and normal
laboratory parameters. Standardized order sets are usually used, and they focus on pre-serving organ function and viability. Immediate action is required for an arterial blood gas value of pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L. The finding indicates metabolic acido-sis. All other values are within normal limits.

DIF: Cognitive Level: Analyze/Analysis REF: p. 239
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

3. The charge nurse is reviewing the status of patients in the critical care unit. Regarding which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation?
a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
b. A 68-year-old patient admitted with unstable atrial fibrillation who has suf-fered a stroke
c. A 40-year-old brain-injured patient with a history of ovarian cancer and a Glasgow Coma Scale score of 7
d. A 53-year-old diabetic with a history of unstable angina status postresuscita-tion

ANS: A
A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other pa-tient scenarios.

DIF: Cognitive Level: Apply/Application REF: Table 11-4
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

4. The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation?
a. A 65-year-old brother with a history of hypertension; blood type A positive
b. A 35-year-old female with a history of food allergies; blood type O negative
c. A 14-year-old son, otherwise healthy with no history; blood type B negative
d. A 70-year-old mother, with a history of sinus infections; blood type A positive

ANS: B
To qualify as a living donor, an individual must be free from hypertension, diabetes, can-cer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food allergies and a blood type of O negative (uni-versal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside acceptable age ranges for living donation. The minor son does not qualify based on blood type.

DIF: Cognitive Level: Apply/Application REF: p. 239
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Adaptation

5. The nurse is caring for a patient who is being evaluated clinically for brain death. Which assessment finding supports brain death?
a. Absence of a corneal reflex
b. Unequal, reactive pupils
c. Withdrawal from painful stimuli
d. Core temperature of 100.8° F

ANS: A
Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.

DIF: Cognitive Level: Understand/Comprehension REF: Table 11-3
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity—Physiological Adaptation

Test Bank For Introduction to Critical Care Nursing 8th Edition by Sole

6. The nurse often assists with brain-death testing. Which patient might have confounding factors for this testing?
a. Patient post motorcycle crash with C2-C3 fracture
b. Patient with massive hemorrhagic stroke
c. Patient with long-standing neuromuscular disease
d. Patient with flail chest and paradoxical chest wall motion.

ANS: A
High spinal cord injury is a confounding factor as it can yield absent responses to brain-stem testing with preserved brain/brainstem function. The other scenarios would not have confounding factors.

DIF: Cognitive Level: Remember/Knowledge REF: Table 11-5
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity

7. The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention?
a. Thirty-degree elevation of head of bed
b. Endotracheal suctioning as needed
c. Frequent side to side repositioning
d. Sequential compression stockings

ANS: B
Denervation of the lung that occurs during lung transplantation causes changes in mucous production and ciliary movement. As a result, to promote the drainage of secretions and prevent mucous plugging, endotracheal and oral suctioning should be a priority of nursing care in the postoperative lung transplant patient. Head of bed elevation, side to side re-positioning, and application of sequential compression stockings are appropriate nursing interventions, but they are not the priority intervention.

DIF: Cognitive Level: Apply/Application REF: p. 244 Lung Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant proce-dures. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity

8. A family member of a gravely ill child approaches the child’s nurse and states, “We want to donate our child’s organs.” What is the best action by the nurse?
a. Arrange a multidisciplinary meeting with physicians.
b. Consult the hospital’s ethics committee for a ruling.
c. Notify the organ procurement organization (OPO).
d. Obtain family consent to withdraw life support.

ANS: C
It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary meeting with physicians and consulting the hospi-tal’s ethics committee are inappropriate actions in this scenario. Informed consent to withdraw life support is provided by the provider.

DIF: Cognitive Level: Apply/Application REF: p. 233
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

9. The nurse is caring for a patient in the critical care unit who, after being de-clared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxy-gen saturation (SpO2) is 99% and core temperature 93.8° F. Which provider prescription should the nurse implement first?
a. Apply forced-air warming device to keep temperature 96.8F.
b. Obtain basic metabolic panel every 4 hours until surgery.
c. Begin phenylephrine (Neo-Synephrine) for systolic BP <90 mm Hg.
d. Draw arterial blood gas every 4 hours until surgery.

ANS: C
Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine (Neo-Synephrine) infusion to get systolic BP >90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this sce-nario.

DIF: Cognitive Level: Apply/Application REF: Table 11-6
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant proce-dures. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity

10. The charge nurse of a transplant unit is reviewing the clinical course of sev-eral transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action?
a. Renal transplant recipient, 1 day post-op with a 3/10 pain level
b. Lung transplant recipient, 1 day post-op with a productive cough
c. Heart transplant recipient, 1 day post-op with a cardiac output of 4 L/min
d. Liver transplant recipient, 2 days post-op with a serum creatinine of 3.7 mg/dL

ANS: D
One complication of liver transplant is renal failure. The patient with the elevated serum creatinine requires immediate action. Postoperative pain level of 3/10 in a renal trans-plant patient, a lung transplant patient with a productive cough, and a heart transplant recipient with a cardiac output of 4 L/min are normal or expected findings, requiring no immediate action.

DIF: Cognitive Level: Apply/Application REF: p. 247 Liver Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant proce-dures. TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity