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?

Serum blood glucose of 128 mg/dL

Blood pressure of 83/51 mmHg

Hemoglobin level of 13 g/dL

Core body temperature of 97.8 degrees F

Answer and Explanation

The Correct Answer is B

Choice A reason:

A serum blood glucose level of 128 mg/dL is slightly elevated but not immediately concerning in the context of organ donation. Blood glucose levels can be managed with insulin if necessary, and this value does not indicate an acute issue requiring immediate intervention.

Choice B reason:

A blood pressure of 83/51 mmHg is critically low and requires immediate action. Low blood pressure can compromise organ perfusion and oxygen delivery, potentially leading to organ damage. In the context of organ donation, maintaining adequate perfusion pressure is essential to ensure the viability of the organs for transplantation.

Choice C reason:

A hemoglobin level of 13 g/dL is within the normal range and does not require immediate intervention. Hemoglobin levels are important for oxygen-carrying capacity but are not the priority concern six hours before organ harvesting if the value is within normal limits.

Choice D reason:

A core body temperature of 97.8 degrees F is slightly below normal but not immediately alarming. Mild hypothermia can be addressed with warming measures, and this temperature does not indicate a critical issue that requires urgent action.

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Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

A. Patient with a Glasgow Coma Scale score that was 9 and is now 12. B. Patient who is requesting pain medication for a new onset headache. C. Patient with a Glasgow Coma Scale score that was 10 and is now 8. D. Patient with a moderate brain injury who is amnesic for the event.

Correct Answer is C

Explanation

Choice A reason:

A Glasgow Coma Scale (GCS) score that improves from 9 to 12 indicates a positive trend in the patient's neurological status. While monitoring is still required, this patient is not the highest priority.

Choice B reason:

A patient requesting pain medication for a new onset headache needs attention, but this is not as urgent as a significant decline in the Glasgow Coma Scale score, which can indicate a deterioration in neurological function.

Choice C reason:

A Glasgow Coma Scale score that drops from 10 to 8 signifies a significant decline in the patient's neurological status, indicating potential worsening of the condition. This patient requires immediate assessment and intervention to identify and address the cause of the deterioration.

Choice D reason:

A patient with a moderate brain injury who is amnesic for the event needs ongoing monitoring, but this is not as urgent as addressing a significant drop in the Glasgow Coma Scale score.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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