A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?
A 72-year-old client with a brain tumor, GCS of 5 and decerebrate posturing.
A 24-year-old client after a motor vehicle accident with a Glasgow Coma Scale (GCS) of 3 and no activity on electroencephalogram.
A 68-year-old male admitted with a massive stroke and GCS of 6.
A 50-year-old female client after a motor vehicle accident and surgical evacuation of an epidural hematoma, Glasgow Coma Scale 12.
The Correct Answer is B
Choice A reason:
A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.
Choice B reason:
A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.
Choice C reason:
A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.
Choice D reason:
A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
While preparing the gastrointestinal tract for enteral feedings is important, it is not the primary reason for administering famotidine. Famotidine is typically used to reduce gastric acid production, not to prepare the GI tract for feedings.
Choice B reason:
Increasing the motility of the gastrointestinal tract is not the primary function of famotidine. Famotidine is an H2 receptor antagonist that works by decreasing the production of stomach acid.
Choice C reason:
Keeping the gastrointestinal tract functioning normally is a broad statement and does not specifically address the reason for administering famotidine. The drug's role in preventing stress ulcers is more relevant to the patient's current condition.
Choice D reason:
Famotidine is used to prevent stress ulcers, which can occur in critically ill patients, including those on mechanical ventilation. The stress of illness and mechanical ventilation increases the risk of developing gastric ulcers, and famotidine helps reduce this risk by decreasing gastric acid secretion.
Correct Answer is D
Explanation
Choice A reason:
While an increased respiratory rate can indicate a compensatory response to shock, it does not directly measure tissue perfusion. It suggests the body is attempting to improve oxygen delivery, but it is not a definitive indicator of adequate tissue perfusion.
Choice B reason:
+1 pedal pulses can indicate decreased perfusion to the extremities, but they do not provide comprehensive information about overall tissue perfusion. Peripheral pulses can be weak in shock due to vasoconstriction and poor circulation, but they are not the most reliable indicator of tissue perfusion.
Choice C reason:
Body temperature is not a direct measure of tissue perfusion. While it is important to monitor, changes in temperature can result from various factors and do not specifically reflect the adequacy of tissue perfusion.
Choice D reason:
Urine output greater than 40 cc/hr is a key indicator of adequate tissue perfusion. The kidneys are highly sensitive to changes in perfusion, and adequate urine output suggests that the kidneys are receiving sufficient blood flow to filter and excrete waste products. Monitoring urine output is a standard practice in assessing tissue perfusion and overall fluid balance in shock patients.
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