A nurse is caring for an infant who has thick nasal secretions, tachypnea, fever, and an oxygen saturation of 90% on room air. Which of the following actions should the nurse take?

Rationale:

A. There is no universal minimum age of 21 for organ donation. In many jurisdictions, individuals as young as 18 can legally consent to organ donation. Additionally, minors may be able to donate with parental or guardian consent depending on local laws. Therefore, this statement provides inaccurate information.

B. Organ donation registration is typically voluntary and can be changed or revoked at any time by the individual while they are alive and competent. Many organ donor registries allow individuals to update or remove their consent status, so the statement is false.

C. Consent for organ donation must be formally documented, commonly through written consent such as signing a donor registry, indicating it on a driver’s license, or completing legal donor authorization forms. This ensures that the individual’s wishes are clearly recorded and legally recognized.

D. There is no general rule that prohibits a nurse from acting as a witness for organ donation consent. Institutional policies may vary, but nurses are often permitted to witness consent forms as part of their professional role unless there is a conflict of interest or specific policy restriction. Therefore, this statement is not universally true and should not be presented as a standard rule.

Rationale:

A. A supine position increases the risk of aspiration of gastric contents, especially in a client with upper gastrointestinal bleeding. The recommended positioning is typically head of bed elevated or side-lying (often left lateral) to help protect the airway and facilitate drainage of gastric contents during lavage.

B. Gastric lavage is performed using room-temperature normal saline, not tap water, to reduce electrolyte imbalance and prevent irritation of the gastric mucosa. Additionally, 400 mL is an excessively large single instillation volume; lavage is typically done in smaller, controlled aliquots to avoid gastric distention and aspiration risk.

C. The goal of gastric lavage in upper GI bleeding is to clear blood and return relatively clear or non-bloody aspirate. Yellow gastric content suggests bile, which is not the target endpoint of lavage and does not indicate successful clearing of hemorrhage.

D. After an episode of upper gastrointestinal bleeding, an NG tube may be left in place for ongoing decompression, monitoring of recurrent bleeding, and prevention of gastric distention. Providing this information is appropriate nursing care because it prepares the client for continued management and reduces anxiety about the presence of the tube.