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 ["B","D","E"]

Explanation

Choice A reason:

Suctioning the patient on a regular schedule is not recommended as it can increase the risk of infection and trauma to the airway. Suctioning should be done as needed based on clinical assessment.

Choice B reason:

Adherence to proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia. Hand hygiene helps prevent the transmission of pathogens.

Choice C reason:

Administering antiulcer medication is important for preventing stress ulcers but is not directly related to preventing ventilator-associated pneumonia.

Choice D reason:

Providing oral care per protocol is essential in reducing the risk of ventilator-associated pneumonia. Oral care helps decrease the bacterial load in the oropharynx and prevent aspiration of contaminated secretions.

Choice E reason:

Elevating the head of the bed to 30-45 degrees helps prevent aspiration of gastric contents and is a key practice in preventing ventilator-associated pneumonia.

A. Lower levels of arterial carbon dioxide facilitate brain oxygenation. B. Carbon dioxide is a waste product that must be eliminated from the body. C. Carbon dioxide is a vasodilator that can cause increased intracranial pressure. D. Lower levels of arterial carbon dioxide (PaCO2) are essential for gas exchange.

Correct Answer is C

Explanation

Choice A reason:

Lower levels of arterial carbon dioxide do not directly facilitate brain oxygenation. While maintaining appropriate CO2 levels is important for overall respiratory function, the primary reason for targeting a specific PaCO2 range in traumatic brain injury is related to intracranial pressure control.

Choice B reason:

Although carbon dioxide is indeed a waste product that must be eliminated from the body, this statement does not explain why specific PaCO2 levels are targeted in the context of traumatic brain injury. The primary concern is the impact of CO2 on intracranial pressure.

Choice C reason:

Carbon dioxide is a potent vasodilator, and elevated levels can lead to increased intracranial pressure (ICP). By maintaining PaCO2 within a range of 35-38 mmHg, the healthcare provider aims to prevent hypercapnia and the resulting vasodilation, which can exacerbate intracranial hypertension in patients with traumatic brain injury.

Choice D reason:

Lower levels of arterial carbon dioxide are not specifically essential for gas exchange. The primary concern with PaCO2 management in traumatic brain injury is controlling intracranial pressure, rather than optimizing gas exchange alone.

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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

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

Correct Answer is ["B","D","E"]

Explanation

Why does the healthcare provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a patient with traumatic brain injury?

Correct Answer is C

Explanation

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