After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

Maintaining proper body positioning

Preventing infection

Maintaining adequate organ perfusion

Avoiding the use of vasopressors

Answer and Explanation

The Correct Answer is C

Choice A reason:

Maintaining proper body positioning is important for the overall care of a patient, but it is not the priority in the context of organ donation. The primary focus should be on ensuring the viability of the organs for transplantation.

Choice B reason:

Preventing infection is critical in any clinical setting, particularly in the care of an organ donor, as infections can compromise the quality of the organs. However, it is not the immediate priority action. The most crucial aspect is maintaining organ perfusion to ensure the organs remain viable for transplantation.

Choice C reason:

Maintaining adequate organ perfusion is the priority nursing action in caring for an organ donor. Adequate perfusion ensures that the organs receive sufficient blood flow and oxygen, which is essential for preserving their function until they can be transplanted. This action takes precedence over other considerations to ensure the success of the organ donation process.

Choice D reason:

Avoiding the use of vasopressors is important because they can impact organ perfusion and function. However, if necessary, vasopressors may be used to maintain adequate blood pressure and perfusion. The overall priority remains ensuring adequate perfusion to preserve organ function.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Palpate the bladder for distention. B. Initiate oxygen via a nasal cannula. C. Place the patient in a supine position. D. Administer a prescribed beta-blocker.

Correct Answer is A

Explanation

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Correct Answer is A

Explanation

The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

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?

The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

A patient with Acute Respiratory Distress Syndrome is mechanically ventilated. Coarse crackles are heard over upper airways, the SaO2 has dropped to 85%, and the patient is agitated. Which action should the nurse take?

The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?