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:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

A. A 72-year-old client with a brain tumor, GCS of 5 and decerebrate posturing. B. A 24-year-old client after a motor vehicle accident with a Glasgow Coma Scale (GCS) of 3 and no activity on electroencephalogram. C. A 68-year-old male admitted with a massive stroke and GCS of 6. D. A 50-year-old female client after a motor vehicle accident and surgical evacuation of an epidural hematoma, Glasgow Coma Scale 12.

Correct Answer is B

Explanation

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.

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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 patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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:

After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?

A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Which would be the most important action immediately following extubation of a patient?

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?