Chapter 16 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 16

Question 1

Type: MCSA

A nurse recognizes that advocating for organ donation is important because:

1. The supply of donor organs meets the demand of potential recipients.

2. Organ recipients are not expected to have a long life span because of complications associated with the transplant.

3. The organ recipient usually enjoys a better quality of life at less cost to the health care system.

4. The organ recipient is often confined by frequent health care visits in order to maintain health.

Correct Answer: 3

Rationale 1: This is not the case today.

Rationale 2: This is not true.

Rationale 3: Organ recipients are expected to live a longer life with better quality, at a lower cost to the health care system.

Rationale 4: The organ recipient needs expert health care but is not confined by frequent visits to maintain health.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1: Describe the criteria used to evaluate living organ donors.

Question 2

Type: MCSA

The nurse is teaching a patient about the antigen-antibody response. Which statement best describes an antigen?

1. Antigens are recognized by the body as foreign or non-self.

2. The presence of HLA antigens means that the recipient cannot receive an organ.

3. A recipient may have antihuman antigens that would react with a donated organ.

4. An organ can only be transplanted if the potential donor and recipient antigens completely match.

Correct Answer: 1

Rationale 1: Antigens are recognized by the body as foreign or non-self.

Rationale 2: HLA antigens found on chromosome 6 helps the immune system determine what tissue is foreign and what is self.

Rationale 3: A recipient may have antihuman antibodies (not antigens) that would react with a donated organ.

Rationale 4: A complete match is rare, and could only occur with identical twins.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-1: Describe the criteria used to evaluate living organ donors.

Question 3

Type: MCSA

The nurse is reviewing the tissue requirements for organ recipients and donors. Which statement correctly describes which recipients can receive an organ from which donor?

1. Recipients with blood type O are universal recipients.

2. Recipients with blood type A can receive donations from donors with blood types A, AB, and O.

3. Recipients with blood type B can receive donations from donors with blood types A, B, and O.

4. Recipients with blood type AB can receive an organ from any donor blood type.

Correct Answer: 4

Rationale 1: Recipients with blood type O are universal donors and not recipients.

Rationale 2: A recipient with blood type A cannot receive a blood type AB donation.

Rationale 3: A recipient with blood type B cannot receive a blood type A donation.

Rationale 4: Recipients with blood type AB are universal recipients and can receive an organ from any donor blood type.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-1: Describe the criteria used to evaluate living organ donors.

Question 4

Type: MCSA

A patient is placed on an organ transplant list for a living or deceased kidney donor. What percentage of organ donors are living organ donors?

1. 20%

2. 30%

3. 40%

4. 50%

Correct Answer: 4

Rationale 1: In 2011, there were approximately 72,000 people awaiting organs but only about 13,000 donors. Approximately half of these donors were living individuals and half were deceased donors.

Rationale 2: In 2011, there were approximately 72,000 people awaiting organs but only about 13,000 donors. Approximately half of these donors were living individuals and half were deceased donors.

Rationale 3: In 2011, there were approximately 72,000 people awaiting organs but only about 13,000 donors. Approximately half of these donors were living individuals and half were deceased donors.

Rationale 4: In 2011, there were approximately 72,000 people awaiting organs but only about 13,000 donors. Approximately half of these donors were living individuals and half were deceased donors.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-1: Describe the criteria used to evaluate living organ donors.

Question 5

Type: MCSA

The critical care nurse is reviewing patients who would be good candidates for organ donation. Which patient would be appropriate for this process?

1. A 25-year-old who is 28 weeks pregnant and has a severe traumatic head injury

2. A 30-year-old who was healthy before overdosing with barbiturates

3. A 45-year-old with a small primary lung carcinoma

4. A 55-year-old with intracranial pressure from a primary intracranial tumor

Correct Answer: 4

Rationale 1: A pregnant patient would not be a candidate for donation until the unborn child had been delivered or had also died.

Rationale 2: Brain death cannot be determined for a patient who was just admitted after overdosing with barbiturates until the drugs are reversed or wear off.

Rationale 3: Any other malignancy such as small primary lung carcinoma would preclude donation.

Rationale 4: The 55-year-old with intracranial pressure is near death (unconscious and on mechanical ventilation) due to pressure from a primary cranial tumor and would be the most appropriate candidate for organ donation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2: Explain the evaluation of a deceased individual for organ donation, including the determination of brain death.

Question 6

Type: MCSA

Which finding by the nurse assessing a potential organ donor would indicate that the patient did not meet the criteria for donation based on brain death?

1. Apnea

2. Decorticate posturing

3. Unresponsiveness

4. Absence of brainstem reflexes

Correct Answer: 2

Rationale 1: Apnea is a cardinal sign of brain death.

Rationale 2: Decorticate posturing is an indication of increased intracranial pressure, but not a cardinal sign of brain death.

Rationale 3: Unresponsiveness is a cardinal sign of brain death.

Rationale 4: Absence of brainstem reflexes is a cardinal sign of brain death.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2: Explain the evaluation of a deceased individual for organ donation, including the determination of brain death.

Question 7

Type: MCSA

The nurse is caring for a patient who is approaching death. When must the nurse notify the organ bank? When:

1. Death is imminent in all cases.

2. Death is imminent and an organ donation card or the back of the drivers license indicates that the person wanted to donate his organs.

3. Death is imminent and the family consents to organ donation.

4. The nurse assesses that the family can be approached about organ donation.

Correct Answer: 1

Rationale 1: It is the law that institutions notify the organ bank when death is imminent.

Rationale 2: Many times an organ donation card is not signed, but the bank must be notified.

Rationale 3: Prior to informing the family, they should have been informed about the death.

Rationale 4: In many cases, the potential donor has not signed a donor card or indicated intent to donate prior to death. Prior to informing the family, they should have been informed about the death.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 8

Type: MCSA

A patient in a critical care area has passed away. Who is the best person to approach the family about organ donation?

1. The nurse

2. The organ procurement specialist

3. The doctor

4. A member of the clergy

Correct Answer: 2

Rationale 1: The nurse is not the best person trained to approach families about organ donation.

Rationale 2: Families are likely to donate if approached by an organ procurement specialist.

Rationale 3: The doctor can discuss organ donation with the family but is not the best person trained to approach families about organ donation.

Rationale 4: The clergy should not approach a family regarding donation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 9

Type: MCSA

What best describes the role of the critical care nurse in the organ donation process?

1. Talk about the benefits of organ donation to the family.

2. Reinforce the explanation of brain death after the doctor has talked to the family.

3. Answer questions about financial concerns related to organ donation.

4. Let the organ procurement nurse take over the care of the patient and family.

Correct Answer: 2

Rationale 1: The organ procurement specialist is the best person to talk about benefits of organ donation with the family.

Rationale 2: It is the nurse who must reinforce the explanations and ensure the familys understanding.

Rationale 3: The organ procurement specialist would be the best person to answer questions about financial concerns of organ donation.

Rationale 4: The nurse has a role with the family and should not permit the organ procurement nurse take over the care of the patient and family.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 10

Type: MCSA

A patients urine output is greater than 200 mL/hour and hemodynamic stability cannot be achieved by using fluids and vasoactive medications. The nurse anticipates that which medication may be prescribed?

1. Beta blocker such as Lopressor

2. Diuretic such as furosemide

3. Concentrated sugar such as 50% dextrose

4. Hormone such as vasopressin

Correct Answer: 4

Rationale 1: A beta blocker would not be indicated for this patient situation.

Rationale 2: A diuretic would not be indicated for this patient situation.

Rationale 3: An infusion of 50% dextrose would not be indicated for this patient situation.

Rationale 4: If hemodynamic stability cannot be achieved using fluids and vasoactive medications, therapy with vasopressin would be instituted. Vasopressin is a synthetic form of antidiuretic hormone (ADH). The expected outcome would be increased vascular volume and decreased urine output.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 11

Type: MCSA

A patient is a candidate for organ donation. A pulmonary artery catheter has been inserted to help maintain hemodynamic stability. Which finding demonstrates that the patient has adequate hemodynamic stability?

1. CVP 5 and PCWP 12

2. CVP 6 and PCWP 10

3. CVP 4 and PCWP 14

4. CVP 3 and PCWP 8

Correct Answer: 2

Rationale 1: This central venous pressure is too low.

Rationale 2: Hemodynamic stability is determined by a CVP of 68 mm Hg and a PCWP of 812 mm Hg.

Rationale 3: This central venous pressure is too low and wedge pressure is too high.

Rationale 4: This central venous pressure is too low.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 12

Type: MCSA

A patient candidate for organ donation has developed diabetes insipidus. What will the nurse most likely assess in this patient?

1. Large urine output and low urine specific gravity

2. Low urine output and high serum sodium

3. High urine specific gravity and high serum glucose

4. Large urine output and low serum sodium

Correct Answer: 1

Rationale 1: DI develops in 40% to 70% of organ donors and results in production of large volumes of dilute urine. Typical findings include: Urine output greater than 300 mL/hr and urine specific gravity less than 1.010.

Rationale 2: A low urine output is not a manifestation of diabetes insipidus.

Rationale 3: A high urine specific gravity is not a manifestation of diabetes insipidus.

Rationale 4: Low serum sodium is not a manifestation of diabetes insipidus.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 13

Type: MCSA

Which intervention is important when the nurse is caring for a patient who is a potential lung donor in order to ensure that the lungs remain suitable for transplant?

1. Maintaining the FiO2 at 98% to 99%

2. Avoiding excess fluid replacement

3. Avoiding frequent suctioning of the donors endotracheal tube

4. Maintaining the donors oxygen saturation at 80%

Correct Answer: 2

Rationale 1: The intent is to attain the highest level of oxygen concentration in the donors blood. FiO2 is to be less than 60%.

Rationale 2: Excess fluid replacement can cause pulmonary edema. Avoiding excessive fluid is essential when recovering lungs for donation.

Rationale 3: Donors receive vigorous pulmonary hygiene and should be suctioned frequently.

Rationale 4: Oxygen saturation is maintained greater than 98%.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 14

Type: MCSA

A patient wants to donate organs after cardiac death. One hour after the withdrawal of life support the patient continues to breathe shallowly and has a slow heartbeat. What is the nurses most appropriate response?

1. Call the patients doctor to reintubate the patient.

2. Update the organ retrieval team that death is imminent.

3. Maintain hemodynamic stability to perfuse the donors organs.

4. Allow death to occur naturally without organ donation.

Correct Answer: 4

Rationale 1: There is no need to reintubate the patient when death is imminent.

Rationale 2: This does not need to be done because the maximum amount of time has passed.

Rationale 3: This does not need to be done because the maximum amount of time has passed.

Rationale 4: An hour is considered the maximum acceptable interval between withdrawal of support and recovery of organs for minimizing ischemic damage. In the process of consent for organ donation, the patient would be allowed to die without resuscitation. However, if the patient continues to breathe with a heart rhythm for 60 minutes, then organ donation is no longer an option and the patient receives palliative care while death occurs naturally.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 15

Type: MCSA

A patient has become a candidate to donate organs in Town A. Based on the UNOS priority system, which potential recipient would be the best candidate to receive a kidney transplant?

1. A patient on dialysis who lives in Town A and has been on the transplant list for 3 years

2. A patient with acute renal failure, the same blood type, and all matching antigens who lives in Town A

3. A patient on dialysis with compatible blood type and six matching antigens who lives in Town B (60 miles away)

4. A patient on dialysis who lives in Town B (60 miles away) and has been on the transplant list for 4 years

Correct Answer: 3

Rationale 1: Being on a transplant list does not make the patient the best candidate without a match.

Rationale 2: The patient has acute renal failure and is not a candidate for transplanting at this time.

Rationale 3: A zero antigen-mismatched organ is when the donor and recipient have compatible blood types, and all six of the HLA antigens match. When this occurs, the organ is offered to the matching potential recipient first.

Rationale 4: Being on the transplant list does not make the patient the best candidate without a match.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-4: Compare and contrast eligibility criteria and evaluation of candidates for kidney, liver, and heart transplants.

Question 16

Type: MCSA

The nurse is determining the MELD score for a patient waiting for a liver transplant. This score contains which criteria?

1. Time on the transplant list, INR, and bilirubin

2. Serum creatinine level, INR, and bilirubin

3. Quality of antigen match, AST, and ALT

4. Severity of illness, AST, ALT, and bilirubin

Correct Answer: 2

Rationale 1: MELD does not consider time on the transplant list.

Rationale 2: The MELD score is calculated using the bilirubin, INR and Creatinine.

Rationale 3: These are not criteria of the MELD score.

Rationale 4: These are not criteria of the MELD score.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-4: Compare and contrast eligibility criteria and evaluation of candidates for kidney, liver, and heart transplants.

Question 17

Type: MCSA

A patient is demonstrating signs of organ rejection 3 months following a kidney transplant. The nurse recognizes this reaction as being what type of rejection?

1. Acute rejection

2. Accelerated rejection

3. Hyperacute rejection

4. Chronic rejection

Correct Answer: 1

Rationale 1: Acute rejection occurs during the first year following organ transplant.

Rationale 2: Accelerated rejection occurs within the first week after transplant.

Rationale 3: Hyperacute rejection occurs immediately and is rare.

Rationale 4: Chronic rejection occurs months to years after organ transplantation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants.

Question 18

Type: MCSA

A patient who developed signs of rejection to a liver transplant within the first week of receiving the organ is asking about the possibility of organ failure. What is the nurses most appropriate response to this patient?

1. You are receiving medications to prevent the rejection. We will continue to do everything to treat the rejection and keep you informed of what is happening.

2. As long as you continue to take your medications to prevent the rejection, everything should be OK with your new liver. I will call the chaplain to visit with you.

3. Although you are receiving medications to prevent the rejection, most people in your situation end up losing their new liver.

4. Please dont worry about rejection right now. You have a new liver and we will give you the medications that you need to treat the rejection.

Correct Answer: 1

Rationale 1: Transplant patients receive medications to prevent rejection and will need to be monitored.

Rationale 2: This statement provides false reassurance to the patient.

Rationale 3: This may or may not be true.

Rationale 4: This does not address the concern of the patient most appropriately.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants.

Question 19

Type: MCSA

A patient recovering from a kidney transplant is taking daclizumab (Zenapex) and has developed a fever and chills with joint pain. What action should the nurse take?

1. Call the doctor immediately and expect orders for Benadryl to treat the drug allergy.

2. Communicate the reaction to the doctor, and expect to hold the medication for 24 hours and then resume it.

3. Continue to give the medication as scheduled and communicate the reaction to the doctor.

4. Call the pharmacy for a suggestion regarding another medication that the patient could take.

Correct Answer: 3

Rationale 1: Immediate action is not warranted. These symptoms do not represent an allergy or an adverse drug reaction.

Rationale 2: After communicating the reaction to the doctor the nurse would expect to receive orders for medications that would help with these symptoms while continuing therapy to prevent organ failure. There is no need to hold the medication.

Rationale 3: Although the patient is showing signs of infection, the medication should be continued and the patient monitored. Fever, chills, and joint pains are common side effects of Rabbit Antithymocyte Globulin (Thymoglobulin).

Rationale 4: The physician would decide whether to change drug therapy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5: Explain the role of immunosuppressants in the prevention and management of rejection.

Question 20

Type: MCSA

What would the nurse include when providing discharge instructions to a patient recovering from a kidney transplant?

1. Your diet should be high in protein and low in carbohydrates.

2. Weigh yourself once a week and notify your physician of any weight gain.

3. You should avoid exercise such as walking for the first week post-op.

4. Contact the transplant center if your cardiologist changes your heart medications.

Correct Answer: 4

Rationale 1: Post-transplant patients should have a diet high in carbohydrates initially.

Rationale 2: Daily rather than weekly measurement of weight measures fluid volume increases.

Rationale 3: Activity such as walking would be encouraged to prevent post-op complications.

Rationale 4: The transplant center will need to know any changes in medications. Many medications interact with immunosuppressants. The nurse would advise the patient to contact the transplant center if starting any new medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-8: Compare and contrast the postoperative collaborative management of patients who have received a transplanted kidney, liver, or heart.

Question 21

Type: MCSA

Which assessment findings would cause the nurse to suspect acute rejection of a transplanted kidney?

1. Protein in the urine

2. High blood pressure

3. Decreased urine output

4. Ketonuria

Correct Answer: 3

Rationale 1: Protein in the urine is not an early sign of acute rejection of a transplanted kidney.

Rationale 2: High blood pressure is not an early sign of acute rejection of a transplanted kidney.

Rationale 3: Decreased urine output is an early sign of acute rejection of a transplanted kidney.

Rationale 4: Ketonuria is not an early sign of acute rejection of a transplanted kidney.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants.

Question 22

Type: MCSA

A patient is being evaluated for rejection after a heart transplant. What will this assessment include?

1. Repeated heart biopsies to assess for myocyte damage or necrosis

2. Signs of chest pain or pain, numbness, or tingling in the left arm

3. 2D echo to assess heart function and left ventricular ejection fraction

4. Signs of heart failure such as sudden weight gain, shortness of breath, and rales on auscultation of the lungs

Correct Answer: 1

Rationale 1: Rejection is diagnosed via endomyocardial biopsies that are performed at regular intervals post-transplant. The postheart transplant patient in early rejection often shows no signs. Therefore, biopsies are important to diagnose early rejection.

Rationale 2: This is not an assessment for transplant rejection.

Rationale 3: This is not an assessment for transplant rejection.

Rationale 4: Late signs of heart rejection include signs of heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants.

Question 23

Type: MCSA

Which intervention is most important to include in the multidisciplinary plan to prevent infection in a patient during the early post-transplant period?

1. Continuing the administration of antibiotics 10 to 14 days post-op

2. Encouraging the patient to ambulate and use an incentive spirometer

3. Keeping the patient on contact precautions for at least 1 week

4. Providing vaccination against the flu virus

Correct Answer: 2

Rationale 1: Prophylactic antibiotics are only used during periods of increased risk, such as during dental procedures, or when an actual infection is present.

Rationale 2: Early ambulation and use of an incentive spirometer are important measures to prevent pneumonia.

Rationale 3: Contact precautions are not necessary. Live vaccines, such as the nasal flu vaccine, are not recommended.

Rationale 4: Live vaccines, such as the nasal flu vaccine, are not recommended.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-7: Discuss prevention and management of infection in transplant recipients.

Question 24

Type: MCSA

A patient 3 months post-transplant is experiencing a sore mouth and throat and is having trouble eating. Upon assessment the nurse sees white patches on the mucous membranes. This patient has probably developed what opportunistic infection?

1. Cytomegalovirus (CMV)

2. Epstein-Barr virus

3. Candidiasis

4. Staphylococcal pneumonia

Correct Answer: 3

Rationale 1: Cytomegalovirus (CMV) is an immunomodulating virus that makes the patient more susceptible to opportunistic infections.

Rationale 2: Epstein Barr virus is an immunomodulating virus that makes the patient more susceptible to opportunistic infections.

Rationale 3: This patient has probably developed candidiasis, which is also commonly known as thrush.

Rationale 4: Staphylococcal pneumonia is not a common opportunistic infection in postorgan transplant patients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-7: Discuss prevention and management of infection in transplant recipients.

Question 25

Type: MCMA

A patient has started taking corticosteroids for immune suppression following transplantation. What should the nurse teach the patient about this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Take this medication 1 hour before or 2 hours after eating.

2. Increased thirst and urination may occur, but should be reported immediately.

3. Your face may have a full or round appearance after taking this medication.

4. You may have a deceased appetite and lose weight while on this medication.

5. Mood swings are common when taking this medication.

Correct Answer: 2,3,5

Rationale 1: Corticosteroids should be taken with food to prevent gastric irritation and ulcerations.

Rationale 2: Increased thirst and urination are signs of diabetes.

Rationale 3: A cushingoid appearance, or full face and trunk, are common side effects of corticosteroids.

Rationale 4: Patients on steroids often gain weight due to increased sodium and water retention as well as increased appetite.

Rationale 5: Mood swings are common side effects of corticosteroids.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 16-5: Explain the role of immunosuppressants in the prevention and management of rejection.

Question 26

Type: MCMA

The mother of a patient wants to be evaluated as a living kidney donor. Which diagnostic tests would the mother need to be considered as a living donor?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Tissue typing

2. Antibody screening

3. Screening for transmissible diseases

4. Renal function tests

5. Chest x-ray

Correct Answer: 1,2,3,4

Rationale 1: This test is done on the donors blood of HLA typing.

Rationale 2: This is a blood test that determines if the recipient has antibodies that could react to any of the donors antigens.

Rationale 3: These are blood tests that determine if the donor has any transmissible diseases like HIV/AIDS, cancer, hepatitis that could potentially be spread to the recipient or affect successful transplantation.

Rationale 4: These include serum creatinine, urea, electrolytes, urinary sediment, albuminuria; 24-hour proteinuria, creatinine clearance, and glycosuria.

Rationale 5: This test is not done as part of determining if a person is eligible to be a living donor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-1: Describe the criteria used to evaluate living organ donors.

Question 27

Type: MCMA

A patient in the intensive care unit is having brainstem reflexes assessed to validate brain death. What assessment findings would validate the diagnosis of brain death?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pupils do not respond to light or accommodation

2. Absent corneal reflex

3. No cough reflex to bronchial suctioning

4. Grimacing to noxious stimuli

5. Involuntary gag reflex upon stimulation of the posterior pharynx

Correct Answer: 1,2,3

Rationale 1: Pupils that are unreactive to light or accommodation indicate brain death.

Rationale 2: A lack of corneal reflexes indicates brain death.

Rationale 3: Absence of cough reflex indicates brain death.

Rationale 4: Grimacing to noxious stimuli indicates intact brain pathways.

Rationale 5: An involuntary gag reflex indicates intact brain pathways.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2: Explain the evaluation of a deceased individual for organ donation, including the determination of brain death.

Question 28

Type: MCMA

The nurse is caring for an organ donor patient who has been diagnosed as brain dead. What will the nurse do to ensure stability of the patients body temperature?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Set the room temperature to 90 degrees Fahrenheit.

2. Administer warm intravenous fluids.

3. Apply warming blankets to the patient.

4. Hyperventilate the patient to decrease arterial carbon dioxide level.

5. Suction frequently.

Correct Answer: 1,2,3

Rationale 1: Following brain death dysfunction of the hypothalamus often occurs. The donor becomes poikilothermic, which means that his body temperature fluctuates with the temperature of the environment. The nurse might adjust the room temperature to about 90 degrees Fahrenheit.

Rationale 2: The administration of warm intravenous fluids will help keep the patients body temperature near normal.

Rationale 3: The use of warming blankets will help maintain a body temperature of about 98 degrees Fahrenheit.

Rationale 4: Hyperventilation helps correct any electrolyte imbalances and not maintain body temperature.

Rationale 5: Frequent suctioning helps maintain adequate oxygenation and not maintain body temperature.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3: Describe collaborative management of the deceased organ donor awaiting organ recovery.

Question 29

Type: MCMA

A patient with end-stage renal disease wants to be considered for a kidney transplant. What would the nurse explain about the United Network for Organ Sharing waiting list process?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Waiting time begins when the patient begins chronic dialysis maintenance.

2. The patients location in proximity to the available kidney is a consideration in determining who will receive the kidney.

3. The number of matches between the candidates and donors HLA antigens is a significant consideration in who will receive an organ.

4. Family members must be available to care for the patient after transplant or the patient will not be placed on the list.

5. Body size

Correct Answer: 1,2,3

Rationale 1: The time of waiting begins when the candidate either has a creatinine clearance less than or equal to 20 mL/min or begins chronic maintenance dialysis.

Rationale 2: Kidneys are allocated first locally, then regionally, and finally, nationally.

Rationale 3: Points are assigned to a candidate based on the number of mismatches between the candidates antigens and the donors antigens at the HLA-DR locus.

Rationale 4: This is not UNOS criteria to be placed on a waiting list for a kidney transplant.

Rationale 5: This is not UNOS criteria to be placed on a waiting list for a kidney transplant.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4: Compare and contrast eligibility criteria and evaluation of candidates for kidney, liver, and heart transplants.

Question 30

Type: MCMA

A patient recovering from a kidney transplant is prescribed tacrolimus (Prograf). What actions will the nurse take when providing this medication to the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Provide the medication orally.

2. Provide the medication in the morning before breakfast.

3. Monitor blood pressure.

4. Assess capillary blood glucose level daily.

5. Administer through a central line with a filter over 6 hours for the first dose.

Correct Answer: 1,2,3,4

Rationale 1: Oral therapy is preferred because of the risk of anaphylactic reactions with the intravenous form of the medication.

Rationale 2: This medication should be taken on an empty stomach in the morning because food intake can limit its absorption by up to 40%.

Rationale 3: This medication can affect blood pressure.

Rationale 4: This medication can cause insulin dependent diabetes mellitus. The patients blood glucose level needs to be assessed frequently.

Rationale 5: The oral form of this medication is preferred because of the risk of anaphylactic reactions with intravenous administration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5: Explain the role of immunosuppressants in the prevention and management of rejection.

Question 31

Type: MCMA

The nurse should suspect that a patient recovering from a liver transplant is experiencing acute rejection if what is found during assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Malaise and fatigue

2. Swollen and tender graft site

3. Colorless bile

4. Tea-colored urine

5. Constipation

Correct Answer: 1,2,3,4

Rationale 1: Malaise and fatigue are manifestations of acute liver transplant rejection.

Rationale 2: A swollen and tender graft site is a manifestation of acute liver transplant rejection.

Rationale 3: A change in color of bile from golden to colorless is a manifestation of acute liver transplant rejection.

Rationale 4: Tea-colored urine is a manifestation of acute liver transplant rejection.

Rationale 5: Constipation is not a manifestation of acute liver transplant rejection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants.

Question 32

Type: MCMA

A patient is being discharged to home after receiving a liver transplant. What can the nurse instruct the patient and family to reduce the risk of developing an infection?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Wash hands before eating and after using the bathroom.

2. Wear a mask when in a crowd for the first few months post-transplant.

3. Remove plants and flowers in vases from the home.

4. Wash, peel, and cook all fruits and vegetables.

5. Obtain vaccinations with live vaccines.

Correct Answer: 1,2,3,4

Rationale 1: Family and patient teaching at the time of discharge from the hospital should focus on self-care practices that prevent infection. Some strategies that may help prevent infection include washing hands before putting anything in or near the mouth and after toileting.

Rationale 2: Family and patient teaching at the time of discharge from the hospital should focus on self-care practices that prevent infection. Some strategies that may help prevent infection include wearing a mask when in a crowd for the first few months post-transplant.

Rationale 3: Family and patient teaching at the time of discharge from the hospital should focus on self-care practices that prevent infection. Some strategies that may help prevent infection include removing plants and flowers in vases from the home.

Rationale 4: Family and patient teaching at the time of discharge from the hospital should focus on self-care practices that prevent infection. Some strategies that may help prevent infection include washing, peeling, and cooking all fruits and vegetables.

Rationale 5: Family and patient teaching at the time of discharge from the hospital should focus on self-care practices that prevent infection. Some strategies that may help prevent infection include avoiding vaccinations with live vaccines.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 16-7: Discuss prevention and management of infection in transplant recipients.

Question 33

Type: MCMA

A patient recovering from a liver transplant is at risk for malnutrition. What would the nurse include when planning care for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Consult with a dietician to plan for adequate energy from carbohydrates or fats.

2. Provide nutritional supplements enterally.

3. Prepare for placement of a central line for parenteral nutrition.

4. Encourage high-protein foods.

5. Restrict fruits and vegetables.

Correct Answer: 1,2

Rationale 1: The goal of nutritional support post-operatively is to provide adequate protein and energy from carbohydrates or fats equivalent to or slightly less than energy expenditure.

Rationale 2: Nutritional requirements are provided enterally.

Rationale 3: Parenteral nutrition is associated with increased risk of infection in the liver transplant recipient.

Rationale 4: Protein intake should be adequate and not more than body needs.

Rationale 5: Fruits and vegetables do not need to be restricted. They should be washed, peeled, and cooked to reduce the risk of infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-8: Compare and contrast the postoperative collaborative management of patients who have received a transplanted kidney, liver, or heart.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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