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Chapter 11: Organ Donation
from TEST BANK for Introduction to Critical Care Nursing 7th Edition by Sole, Kelein, Mosley.
by StudyGuide
Sole: Introduction to Critical Care Nursing, 7th Edition
Multiple Choice
1. The nurse is caring for a patient who has a Glasgow Coma Scale (GCS) score of 3. Discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?
a. “I need to notify the local Organ Procurement Organization of my patient’s impending death.” b. “I will contact the provider to obtain informed consent for organ donation.” c. “The charge nurse will notify the local Organ Procurement Organization once the patient has been pronounced brain dead.” d. “I need the physician to evaluate my patient’s suitability for organ donation.”
ANS: A
Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the provider, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur before death, not after the patient has been pronounced dead.
DIF: Cognitive Level: Understand/Comprehension
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
NURSINGTB.COM
REF: p. 233
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8° F d. Central venous pressure of 8 mm Hg
2. The nurse is managing a donor patient six hours before the scheduled harvesting of the patient’s organs. Which assessment finding requires immediate action by the nurse?
ANS: B
Donor management focuses on maintaining hemodynamic stability and normal laboratory parameters. Standardized order sets are usually used, and they focus on preserving organ function and viability. Immediate action is required for an arterial blood gas value of pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L. The finding indicates metabolic acidosis. All other values are within normal limits.
DIF: Cognitive Level: Analyze/Analysis REF: p. 239
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old patient admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured patient with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic with a history of unstable angina status postresuscitation
3. The charge nurse is reviewing the status of patients in the critical care unit. Regarding which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation?
ANS: A
A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other patient scenarios.
DIF: Cognitive Level: Apply/Application
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
REF: Table 11-4
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. A 65-year-old brother with a history of hypertension; blood type A positive b. A 35-year-old female with a history of food allergies; blood type Onegative c. A 14-year-old son, otherwise healthy with no history; blood type B negative
4. The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation?
NURSINGTB.COM d. A 70-year-old mother, with a history of sinus infections; blood type A positive
ANS: B
To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food allergies and a blood type of O negative (universal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside acceptable age ranges for living donation. The minor son does not qualify based on blood type.
DIF: Cognitive Level: Apply/Application REF: p. 239
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Adaptation a. Absence of a corneal reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8° F
5. The nurse is caring for a patient who is being evaluated clinically for brain death. Which assessment finding supports brain death?
ANS: A
Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.
DIF: Cognitive Level: Understand/Comprehension REF: Table 11-3
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity Physiological Adaptation a. Patient post motorcycle crash with C2-C3 fracture b. Patient with massive hemorrhagic stroke c. Patient with long-standing neuromuscular disease d. Patient with flail chest and paradoxical chest wall motion.
6. The nurse often assists with brain-death testing. Which patient might have confounding factors for this testing?
ANS: A
High spinal cord injury is a confounding factor as it can yield absent responses to brainstem testing with preserved brain/brainstem function. The other scenarios would not have confounding factors.
DIF: Cognitive Level: Remember/Knowledge REF: Table 11-5
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Thirty-degree elevation of head of bed b. Endotracheal suctioning as needed c. Frequent side to side repositioning d. Sequential compression stockings
7. The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention?
ANS: B
Denervation of the lung that occurs during lung transplantation causes changes in mucous production and ciliary movement. As a result, to promote the drainage of secretions and prevent mucous plugging, endotracheal and oral suctioning should be a priority of nursing care in the postoperative lung transplant patient. Head of bed elevation, side to side repositioning, and application of sequential compression stockings are appropriate nursing interventions, but they are not the priority intervention.
DIF: Cognitive Level: Apply/Application
REF: p. 244 Lung Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospital’s ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.
8. A family member of a gravely ill child approaches the child’s nurse and states, “We want to donate our child’s organs.” What is the best action by the nurse?
ANS: C
It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary meeting with physicians and consulting the hospital’s ethics committee are inappropriate actions in this scenario. Informed consent to withdraw life support is provided by the provider.
DIF: Cognitive Level: Apply/Application
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
REF: p. 233
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Apply forced-air warming device to keep temperature 96.8 F. b. Obtain basic metabolic panel every 4 hours until surgery. c. Begin phenylephrine (Neo-Synephrine) for systolic BP <90 mm Hg. d. Draw arterial blood gas every 4 hours until surgery.
9. The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8° F. Which provider prescription should the nurse implement first?
ANS: C
Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine (Neo-Synephrine) infusion to get systolic BP >90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this scenario.
NURSINGTB.COM
DIF: Cognitive Level: Apply/Application
REF: Table 11-6
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Renal transplant recipient, 1 day post-op with a 3/10 pain level b. Lung transplant recipient, 1 day post-op with a productive cough c. Heart transplant recipient, 1 day post-op with a cardiac output of 4 L/min d. Liver transplant recipient, 2 days post-op with a serum creatinine of 3.7 mg/dL
10. The charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action?
ANS: D
One complication of liver transplant is renal failure. The patient with the elevated serum creatinine requires immediate action. Postoperative pain level of 3/10 in a renal transplant patient, a lung transplant patient with a productive cough, and a heart transplant recipient with a cardiac output of 4 L/min are normal or expected findings, requiring no immediate action.
DIF: Cognitive Level: Apply/Application REF: p. 247 Liver Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered.
11. The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Blood pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula; temperature is 97.8° F; and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse?
ANS: A
Fluid replacement therapy is a priority in a postoperative renal transplant patient; a CVP of 2 mm Hg and elevated heart rate indicate hypovolemia. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is normothermic; application of active warming measures is not indicated. Although pain assessment is an important part of postoperative nursing care, it is not the priority in this scenario.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 245 Kidney Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
NURSINGTB.COM a. “Your kidney has unfortunately failed and will be removed.” b. “It can take a few days for your kidney to start working.” c. “You are experiencing an acute rejection episode.” d. “You will have to have daily hemodialysis until a new donor is found.”
12. The nurse is caring for a postoperative renal transplant recipient from a cadaver donor in the critical care unit. After seeing minimal urine output in the catheter for most of the day, the patient expresses concern to the nurse. What is the best response by the nurse?
ANS: B
There are many factors that can delay normal functioning of a transplanted renal graft (e.g., prolonged cold times, altered perfusion states during surgery). A kidney from a cadaver may not function immediately, and hemodialysis may be needed until it functions adequately. This is not necessarily a sign that the kidneys have failed and need removal or that the patient is experiencing acute rejection. There is also no indication that a retransplant needs to occur.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 245 Kidney Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity Physiological Adaptation a. Nitroprusside b. Esmolol c. Dobutamine d. Normal saline
13. A patient being cared for in the ICU before organ donation shows increased PVCs on the cardiac monitor What medication does the nurse prepare to administer first?
ANS: B
Esmolol is a beta blocker used to control tachycardia and decrease myocardial oxygen consumption from catecholamine release, and it protects heart muscle from ischemia. An increase in PVCs indicates increased cardiac irritability, perhaps from cellular ischemia. The other drugs would not be indicated.
DIF: Cognitive Level: Analyze/Analysis
REF: Table 11-6
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Immunosuppressant medications reduce the body’s ability to fight infections. b. During the early postoperative period, atelectasis decreases oxygenation. c. Pulmonary hygiene reduces the risk of early primary graft dysfunction. d. Loss of cough reflex results in decreased ability to remove secretions effectively.
14. The nurse is caring for a patient following a bilateral lung transplant. When planning postoperative care of the patient, priority is placed on pulmonary hygiene. Which statement provides the best explanation for this priority?
ANS: D
Nerves of the autonomic nervous system are severed during lung transplant surgery. This results in denervation of the lung and loss of the cough reflex. Loss of this reflex places the patient at greater risk for infection because of the potential inability to clear secretions effectively. Although immunosuppressant medications reduce the body’s ability to fight infections, this is a general explanation for all increased risk of infection in transplant recipients. Atelectasis decreases oxygenation. The primary reason for pulmonary hygiene is to expectorate secretions. Primary graft dysfunction is caused by ischemia, surgical trauma, or denervation and is similar to acute respiratory distress syndrome.
NURSINGTB.COM
DIF: Cognitive Level: Understand/Comprehension
REF: p. 244 Lung Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Notify the OPO transplant coordinator. b. Verify results with the lab technician. c. Repeat all preprocedure viral studies. d. Continue to monitor for signs of rejection.
15. While following up on a postoperative renal transplant recipient, the nurse discovers that the patient tested positive for cytomegalovirus (CMV). What is the priority action by the nurse?
ANS: A
It is mandatory to report any donor-derived infections to the organ procurement organization (OPO). The priority action is to notify the transplant coordinator. Verifying results with the lab technician, if indicated, would be the responsibility of the transplant coordinator. Repeating viral studies and continuing to monitor for signs of rejection are appropriate actions but not the immediate priority.
DIF: Cognitive Level: Apply/Application
REF: p. 239
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Vasopressin b. Methylprednisolone c. Desmopressin acetate d. Esmolol
16. A nurse is caring for a patient declared brain dead following a car crash in preparation for the harvesting of organs. The patient’s urine output was 1050 mL in the last hour. What medication does the nurse prepare to administer?
ANS: C
The patient’s history and urine output point to diabetes insipidus. The nurse should prepare to administer desmopressin acetate to control the urine output. Vasopressin, methylprednisolone, and esmolol would not be warranted.
DIF: Cognitive Level: Analyze/Analysis REF: Table 11-6
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Blood pressure of 100/60 mm Hg b. Serum creatinine of 1.5 mg/dL c. Hemoglobin of 9.2 gm/dL d. Tenderness over graft site
17. The nurse obtains initial vital signs on a patient 2 weeks post–liver transplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action?
ANS: D
Tenderness over the graft site may be indicative of acute rejection in a liver transplant recipient 2 weeks posttransplant. Blood pressure, serum creatinine, and hemoglobin values are all within acceptable ranges and do not require immediate action.
DIF: Cognitive Level: Apply/Application
REF: p. 248 Liver Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. “I only smoke marijuana on an occasional basis.” b. “I have two sisters who live within two hours of me.” c. “I have attended all of my scheduled dialysis sessions.” d. “My mother’s side of the family has a history of cancer.”
18. The transplant clinic social worker is completing a social history on a patient with end-stage renal disease who is being evaluated for transplant. Which statement by the patient warrants further action?
ANS: A
IV drug use is a contraindication to transplantation. A patient who reports using any recreational drugs should be evaluated further for other types of drug use. Family support is critical during posttransplant care. Adherence to dialysis indicates probable success in adhering to future treatment plans. A patient history of active or recent malignancy is a contraindication to transplantation.
DIF: Cognitive Level: Apply/Application
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
REF: p. 238
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance a. “I qualify if I have end-stage renal disease.” b. “I will not qualify until I have to go on regular hemodialysis treatments.” c. “My blood type does not have to be a match with the donor blood type.” d. “The national waiting list is based on the ability to pay for medications.”
19. The transplant clinic nurse is educating a patient about the renal criteria that must be met in order to be placed on the transplant waiting list. Which statement by the patient best indicates an understanding of the criteria?
ANS: A
Candidates are placed on the UNOS national waiting list once they have end-stage renal disease. Patients may be on dialysis or have a glomerular filtration rate of less than 5 to 20 mL/minute. ABO compatibility is necessary for successful renal transplantation. A point system is used to rank candidates to determine who will receive a kidney when a donor becomes available.
DIF: Cognitive Level: Evaluate/Evaluation
NURSINGTB.COM
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: p. 244 Lung Transplant Box a. “I will be gradually weaned off my medications during my lifetime.” b. “After 6 months, I will be down to taking one medication for life.” c. “Complications of these medications include diabetes, infection, hypertension, and bone loss.” d. “I will only need to take my mediations every other day for life.”
20. The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the patient best indicates an appropriate understanding?
ANS: C
Posttransplant recipients will be on immunosuppressant medications for life. They have many side effects, including nephrotoxicity, hypertension, hyperlipidemia, bone loss, new-onset diabetes mellitus, and infection.
DIF: Cognitive Level: Evaluate/Evaluation
REF: p. 245 Kidney Transplant Box
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. The patient is having rejection. b. The patient is being monitored for rejection. c. The new heart is functioning poorly. d. The patient is being evaluated for a repeat transplant.
21. A nurse is preparing to admit a post-heart transplant patient for a second myocardial biopsy in 3 weeks. What conclusion does the nurse draw from this admission information?
ANS: B
After heart transplant, patients undergo myocardial biopsy every week for 4-6 weeks. After that period of time, biopsies are scheduled based on patient condition. The patient is not necessarily rejecting the heart, there is no indication the heart is not functioning well, and the patient is not being evaluated for a new transplant.
DIF: Cognitive Level: Remember/Knowledge
OBJ: Discuss processes associated with organ donation. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: p. 246 Heart Transplant Box a. “Endomyocardial biopsies will be performed weekly for the first 6 weeks after surgery.” b. “Increased shortness of breath most likely indicates immediate, acute rejection of the heart.” c. “Biopsies of the heart are done every 6 months after the day of the transplant surgery.” d. “As time passes, the more biopsies that are performed, the more reliable the results become.”
22. The nurse is providing postoperative education to a heart transplant patient’s family. When asked about detecting rejection, which answer by the nurse is most appropriate?
ANS: A
NURSINGTB.COM
The traditional method of rejection surveillance in a heart transplant recipient is through endometrial biopsies performed weekly during the first 6 weeks posttransplant. Shortness of breath can be a symptom of rejection, but only in combination with other symptoms. Rejection is confirmed through biopsy. The need for biopsies decreases over time unless the patient suffers signs and symptoms suggestive of rejection.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 246 Heart Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. “A score is calculated based upon kidney function, clotting time, and bilirubin levels.” b. “A score is calculated that ranges between 6 and 40, with the lower score being more serious.” c. “There are currently no exceptions to the MELD score calculation for severity of disease.” d. “The calculated score represents the patient’s risk of death within 1 year of diagnosis.”
23. The transplant clinic nurse is conducting a pretransplant education session for patients being evaluated for liver transplantation. Which statement by the nurse provides the best explanation of the numeric system used to classify the severity of a patient’s liver disease?
ANS: A
The Model for End-Stage Liver Disease (MELD) score uses the patient’s serum creatinine, international normalized ratio (INR) for prothrombin time, and serum bilirubin to predict survival. The MELD score measures the severity of liver disease. Higher calculated MELD scores indicate a more critically ill patient. MELD exception points may be generated by the presence of hepatocellular carcinoma (HCC), worsening hypoxemia, ascites, or other consequences of liver disease.
DIF: Cognitive Level: Understand/Comprehension
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: p. 247 Liver Transplant Box a. Blood type and HLA tissue type b. HLA tissue type and body type c. Blood type and body size d. Blood type and donor history
24. Which statement best represents appropriate donor-to-recipient criteria for liver transplantation?
ANS: C
Blood type and body size are the two criteria necessary for matching a donor liver to a recipient. HLA tissue typing is not used because it has not been known to affect outcomes. Donors are carefully screened for infectious diseases and carcinomas during the process, but blood type and body type are the essential matching criteria.
DIF: Cognitive Level: Remember/Knowledge
OBJ: Discuss processes associated with organ donation.
NURSINGTB.COM
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: p. 247 Liver Transplant Box a. Notify the provider of liver enzyme results. b. Treat hypoglycemia with 50 mL 5% dextrose. c. Repeat the liver enzyme results in 4 hours. d. Prepare to administer IV insulin infusion.
25. The nurse assesses morning lab results for a postoperative day 1 liver transplant recipient. Lab results noted by the nurse include aspartate transaminase (AST) 365 U/L; alanine aminotransferase (ALT) 400 U/L; and serum glucose of 85 mg/dL. What is the best action by the nurse?
ANS: A
Rejection is suspected with a rise in aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin and warrants a liver biopsy. These values are very high, which warrants notifying the provider. Glucose of 85 mg/dL is considered within normal limits by most laboratories and would not require treatment with glucose or insulin to normalize. Repeating the enzyme results in 4 hours would be appropriate, but it is not the immediate priority.
DIF: Cognitive Level: Apply/Application
REF: pp. 247-248 Liver Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity a. “Adhere to all future scheduled appointments with the clinic.” b. “Obtain annual vaccinations for pneumonia from your physician.” c. “Report all routine lab results to your primary care physician.” d. “Notify the transplant clinic of all future hospital admissions.”
26. The transplant clinic nurse is educating a group of transplant recipients on health promotion and maintenance. What is the priority statement by the nurse?
ANS: B
To protect against viruses that would be detrimental to a transplant recipient, it is most important for transplant patients to consult with their clinic providers to obtain the appropriate vaccinations. Adherence to future scheduled appointments, reporting lab results, and notifying the clinic of all future hospitalizations are part of long-term care, but appropriate vaccinations are essential to the health of the patient.
DIF: Cognitive Level: Apply/Application
REF: this info is in each organ transplant box
OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance a. The patient is at increased risk for infection. b. The patient has developed posttransplant diabetes. c. Temporary elevations in blood sugars are normal. d. Discontinuation of steroids will normalize values.
27. A renal transplant recipient presents to the outpatient transplant clinic with blood glucose values for the past 3 days exceeding 250 mg/dL. The patient takes prednisone 5 mg daily and tacrolimus (Prograf) 2 mg twice daily. Hemoglobin A1C level drawn the day of the clinic appointment was 8.5%. What is the best interpretation of this finding by the nurse?
ANS: B
A patient taking steroids and calcineurin inhibitors is at risk for the development of posttransplant diabetes as a complication of long-term medication therapy. Although the lab values in isolation do not indicate infection, blood sugars must be normalized to promote healing. Hemoglobin A1C levels indicate the level of blood sugar control over the past 2 to 3 months. Findings should not be considered temporary. Although steroids can elevate blood sugar values, discontinuation of steroid therapy may not be feasible in all transplant recipients.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 245 Kidney Transplant Box
OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. The drug is administered for recipients of CMV-positive donor organs. b. Administration of the drug decreases initial postoperative rejection rates. c. Antiproliferative agents are recommended for routine induction therapy. d. Antithymocyte globulin (ATG) is given as a single dose in the OR.
28. The postanesthesia care unit receives handoff communication from the CRNA indicating that the renal transplant recipient received induction therapy in the operating room with antithymocyte globulin (ATG). What is the best understanding of the administration of this drug by the nurse?
ANS: B
Administration of antiproliferative agents such as antithymocyte globulin (ATG) has been shown to decrease rejection rates in the initial postoperative period. Antiviral agents are administered if CMV donor status is positive. Antiproliferative agents are recommended as first choice for induction therapy in recipients at high immunological risk. ATG is given in the operating room as well as for several days postoperative.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 246 Heart Transplant Box
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. It is a calcineurin inhibitor used for induction therapy. b. It is an antimetabolite used for maintenance therapy. c. It is an antiproliferative agent used for maintenance therapy. d. It is an mTOR inhibitor used for maintenance therapy.
29. The nurse is preparing to administer a renal transplant recipient’s first dose of mycophenolate mofetil (CellCept). What is the best understanding of this medication by the nurse?
ANS: C
Mycophenolate mofetil (CellCept) is an antiproliferative agent that inhibits T lymphocytes. CellCept is used for maintenance immunosuppression therapy.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 246 Heart Transplant Box
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
TOP: Nursing Process Step: Planning
NURSINGTB.COM
MSC: NCLEX Client Needs Category: Physiological Integrity a. “To be a living donor, you must be related to the recipient.” b. “You must be over the age of 30 to be a living donor.” c. “Living donor donation is coordinated by UNOS.” d. “Let us orient you to the process required to become a donor.”
30. A patient presents to the outpatient transplant clinic stating, “I would like to donate one of my kidneys.” What is the best response by the nurse?
ANS: D
An altruistic living donor is an individual who makes a decision to donate an organ or part of an organ to a stranger. The nurse can help the patient navigate the donation process. Living donors may be related or unrelated to the potential recipient. In general, living donors are usually between the ages of 18 and 60 years. All transplant centers coordinate the living donation process.
DIF: Cognitive Level: Apply/Application
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
REF: p. 234
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. A cardiac transplant patient with a 3-month history of shortness of breath b. A lung transplant patient with small pustules that follow a dermatome c. A liver transplant patient with several small lumps under the skin d. An implanted renal transplant that, upon reperfusion, becomes cyanotic
31. Which clinical scenario best represents hyperacute rejection?
ANS: D
A hyperacute rejection occurs within hours or days of the transplanted organ. An implanted renal transplant that becomes cyanotic upon reperfusion represents a hyperacute rejection. A cardiac transplant patient with a 3-month history of shortness of breath represents an acute rejection. Small pustules that follow a dermatome most likely represent herpes zoster. Several small lumps under the skin may indicate squamous cell carcinoma.
DIF: Cognitive Level: Remember/Knowledge
REF: pp. 244-246
OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity a. The LAS estimates the probability of survival and benefits from transplantation. b. Lungs from children and adolescents are offered to adults first. c. The LAS is limited to candidates under the age of 65 years. d. The score was developed to estimate 5-year survival rates.
32. Which statement best describes the lung allocation score (LAS) used to prioritize lung transplant recipients?
ANS: A
The LAS generates a score that estimates the probability of survival posttransplant and the benefits of transplant for potential lung recipients. Lungs from children and adults are offered to pediatric and adolescent candidates first. The LAS is used for all patients who are listed on the organ donor registry. The LAS was developed to estimate the change of first-year survival after transplantation.
NURSINGTB.COM
DIF: Cognitive Level: Remember/Knowledge
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: p. 244 Lung Transplant Box a. Administer an extra dose of the ordered pain medication. b. Administer a 500-mL bolus of 0.9% normal saline intravenously stat. c. Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline. d. Provide maintenance IV fluids of D5 0.45% normal saling to infuse at 100 mL/hr.
33. The nurse is caring for a renal transplant recipient in the postanesthesia care unit (PACU). One hour after the transplant recipient was admitted to the PACU, the RN notes the patient’s blood pressure has dropped to 82/60 mm Hg and the pulse is 138 beats/min. Which physician order should the nurse implement first?
ANS: C
Surgical complications following renal transplantation include arterial or venous bleeding due to failure of the surgical anastomoses. A fluid bolus can replace preload temporarily until the provider determines the cause of this change in status. Extra pain medications may or may not be needed. Irrigating the catheter is not related to this scenario. Hypotonic fluids are generally not used in the immediate postoperative period.
DIF: Cognitive Level: Apply/Application
REF: p. 245 Kidney Transplant Box
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. “Your admission lab results will determine whether your kidney is being rejected.” b. “A procedure called a renal biopsy will be the best way to confirm rejection.” c. “Monitoring over the next few days will determine whether your kidney is failing.” d. “An ultrasound of your kidney will determine whether your kidney has failed.”
34. The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The patient asks the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse?
ANS: B
Renal biopsy confirms the presence of rejection. Admission lab results will provide information related to the current functional level of the kidney but will not confirm rejection. Monitoring the patient will not confirm the presence of rejection. An ultrasound of the kidney will determine whether there is blood flow to the kidney but will not provide information at the cellular level.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 245 Kidney Transplant Box
OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
Multiple Response
NURSINGTB.COM a. Donor disfigurement influences on funeral care b. Fear of inferior medical care provided to donor c. Age and location of all possible organ recipients d. Concern that donated organs will not be used e. Fear that the potential donor may not be deceased f. Concern over financial costs associated with donation
1. The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, the nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
ANS: A, B, E, F
Common fears and concerns that can influence a family’s decision to donate include fear of disfigurement of the donor, fear of inferior medical care being provided to the donor in order to hasten the process, fear that the donor may not really be deceased, and concern that the family of the donor will assume the financial burden associated with the donation. The number of individuals awaiting transplant, along with the current UNOS registry system, ensures that all procured organs will be transplanted. The age and location of recipients are not disclosed by the OPO.
DIF: Cognitive Level: Understand/Comprehension REF: p. 236
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
