Chapter 38 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 38

Question 1

Type: MCSA

A patient being prepared for a heart transplant is concerned that the transplanted organ will not be accepted in his body. What should the nurse consider when formulating a response to this concern?

1. Heart transplants are very successful because of immunosuppressant medication.

2. Today it is more common to do heartlung transplants.

3. Hearts were the first organs to be transplanted so the technique has been perfected.

4. There are no guarantees since transplants are more successful between twins.

Correct Answer: 1

Rationale 1: Cardiac transplantation is highly successful today, in part because of tissue typing and improved immunosuppressant therapy.

Rationale 2: Both heart and heartlung transplants are successful today.

Rationale 3: The first transplants were done in the 1950s and were kidney transplants. Heart transplants were first successful in the mid-to-late 1960s.

Rationale 4: Identical twin transplants are the most successful, but much success has also been demonstrated with non-twin transplants.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-1

Question 2

Type: MCSA

A patient tells the nurse that chronic kidney disease is in his family and his father died within a few months after having a kidney transplant in the late 1940s. What information should the nurse provide?

1. Your chances of a successful transplant depend upon finding a healthy family member who is a match and will agree to provide an organ.

2. The most successful transplants have always been the heart and lungs.

3. Many of the earlier failures of kidney transplants had to do with suturing technique.

4. Medications to prevent problems associated with organ transplantation are now widely available.

Correct Answer: 4

Rationale 1: Many non-family transplants are performed and are successful.

Rationale 2: Transplanting the heart and lungs did not receive the focus of transplantable organs until the 1980s. There is no evidence that transplant of these organs is more successful than transplant of other organs.

Rationale 3: The major problem associated with transplant has always been rejection.

Rationale 4: Cyclosporine and other antirejection drugs are now available and have made transplant surgeries much more successful.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-1

Question 3

Type: MCSA

The older brother of a patient in renal failure has agreed to donate a kidney. Testing reveals that the brothers are a good match for this procedure. How would the nurse describe this treatment plan?

1. Heterograft living donor

2. Histograft living donor

3. Allograft living donor

4. Isograft living donor

Correct Answer: 3

Rationale 1: Heterograft is the transplantation of tissue between two different species.

Rationale 2: Histograft is not a term used to describe status of the donor. Histocompatible refers to the compatibility between donor and recipient.

Rationale 3: An allograft refers to tissue that is transplanted within the same species. A living donor is someone who agrees to have body parts transplanted into another person while alive. The patients brother is an allograft living donor.

Rationale 4: Isograft refers to tissue transplanted between twins.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-2

Question 4

Type: MCSA

A patient is scheduled to receive a liver for transplantation from a person who has died. The nurse anticipates that the donor has which characteristic?

1. Died of natural causes

2. Experienced cardiac death

3. Died in an automobile accident

4. Experienced brain death

Correct Answer: 4

Rationale 1: It is not possible for the nurse to know if the donor died from natural causes.

Rationale 2: Cardiac death refers to death by cessation of cardiac and respiratory function. This type of death limits the kinds of tissues that can be donated and typically excludes organ donation.

Rationale 3: The method of death is not predictable.

Rationale 4: There are two types of cadaver donors. Organ donors from cadavers who have died from brain death comprise the largest number of implantable organs.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-2

Question 5

Type: MCMA

A patient, identified as a potential organ donor, has been diagnosed as brain dead and is being maintained on ventilator support. The nurse is reviewing the patients hemodynamic parameters and is concerned about which findings?

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

Standard Text: Select all that apply.

1. Mean arterial pressure 50 mm Hg

2. Central venous pressure 5 mm Hg

3. Serum sodium 145 mEq/L

4. Serum glucose 170 mg/dL

5. Ejection fraction 30%

Correct Answer: 1,5

Rationale 1: There are specific hemodynamic parameters that an adult potential organ donor must meet. The mean arterial pressure should be between 60 and 110 mm Hg.

Rationale 2: Acceptable CVP ranges are 412 mm Hg.

Rationale 3: Acceptable serum sodiums are less than 155 mEq/L.

Rationale 4: Acceptable serum glucose readings are less than 180 mg/dL.

Rationale 5: The desirable range for ejection fraction is above 50%.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-4

Question 6

Type: MCSA

A patient, identified as an organ donor, is diagnosed as being brain dead. The organ procurement organization (OPO) rules that the patient is not a candidate for transplant. The nurse would attribute this decision to which patient history?

1. Experimented with intravenous heroin 20 years prior

2. Being treated for hepatitis B

3. Treated for prostate cancer one year ago

4. Treated for shock

Correct Answer: 2

Rationale 1: Drug abuse many years ago would be considered, but is not the most likely reason this patients donor status was denied.

Rationale 2: Transplantation from a donor with active hepatitis B causes risk for transmission to the recipient. This is the most likely reason that this patients donor status was denied.

Rationale 3: History of cancer, particularly if the cancer is in remission, is localized, and if not bloodborne does not eliminate a person from being a donor.

Rationale 4: Treatment for shock may or may not result in the organs being unsuitable. The patient would likely be considered as a donor.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-5

Question 7

Type: MCSA

The nurse is caring for a patient who will be an organ donor. Which nursing intervention is indicated to protect endocrine function?

1. Provide bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by continuous levothyroxine intravenous infusion.

2. Administer salt poor intravenous fluid.

3. Administer blood transfusion.

4. Provide intravenous dopamine.

Correct Answer: 1

Rationale 1: Management of the patient who is an identified organ donor includes maintaining endocrine stability. To do this, the thyroid protocol should be implemented which is to provide a bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by a continuous levothyroxine intravenous infusion.

Rationale 2: Salt poor intravenous fluids are used to manage the renal/fluid/electrolyte status.

Rationale 3: Blood transfusions are used to manage the hematopoietic status.

Rationale 4: Intravenous dopamine is used to manage the patients hemodynamic status.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-4

Question 8

Type: MCSA

A patient awaiting a kidney transplant has O blood type. The nurse would explain that the patients kidney can come from someone with which blood type?

1. Only O

2. B or O

3. A or O

4. A, B, or O

Correct Answer: 1

Rationale 1: If an organ recipients blood type is O, the only blood type of an organ donator that the recipient can receive must also be O.

Rationale 2: If the organ recipient has the blood type of B, organs from donors with B or O can be received.

Rationale 3: An organ recipient with the blood type A can receive an organ from a donor with the blood type of either A or O.

Rationale 4: If the recipient has the blood type of AB, organs from donors with A, B, or O can be received.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-6

Question 9

Type: MCSA

A patient who received a kidney transplant 2 years ago has been diagnosed with skin cancer. He tells the nurse that he cannot believe that he has cancer since he has already gone through so much with the kidney disease. How should the nurse respond to this patients statement?

1. It is unusual for malignancies to develop this long after transplant.

2. Patients on long-term medications to prevent organ rejection are at risk for developing cancer.

3. At least this cancer will not affect the transplanted kidney.

4. Everyone can develop cancer at any time.

Correct Answer: 2

Rationale 1: Cancers can develop as soon as 6 months after transplant surgery or may not develop for 10 to 15 years after surgery.

Rationale 2: Patients on long-term immunosuppressant therapy are at increased risk for development of some form of malignancy.

Rationale 3: It is unknown whether this cancer, which may be melanoma, will or will not affect the transplanted kidney.

Rationale 4: This is a true statement but does not address this patients concerns.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-8

Question 10

Type: MCSA

It has been determined that a patient who received hematopoietic stem cell transplantation is having poor functioning of the graft. The nurse would prepare the patient for which intervention?

1. Administration of high dose corticosteroids

2. A second stem cell infusion

3. Administration of platelets

4. Surgery to remove the graft

Correct Answer: 2

Rationale 1: Corticosteroids are included in the management of the patient experiencing graft versus host disease.

Rationale 2: If the initial graft fails a second stem cell infusion may be possible.

Rationale 3: The administration of platelets or red blood cells would be indicated in the management of the patient experiencing severe pancytopenia.

Rationale 4: Surgery to remove a stem cell graft is not possible.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-10

Question 11

Type: MCSA

A patient received allogeneic hematopoietic stem cell transplantation 2 days ago. Which information should the nurse provide?

1. Your body is accepting the transplanted cells so you should be feeling a lot better.

2. Your body is making normal hematopoietic cells.

3. You feel so bad because the transplanted cells are attacking your tissues, but that is normal and will pass.

4. You may not feel well today and we need to protect you from exposure to any infections.

Correct Answer: 4

Rationale 1: This is a period in which the patient will not feel much better.

Rationale 2: It can take up to 5 weeks for the body to make normal hematopoietic cells and not 2 days.

Rationale 3: If graft vs. host disease is occurring the patient will feel sick but GVHD does not pass nor is it normal.

Rationale 4: Within 2 to 3 days after the transplant, the patients bone marrow function drops to its lowest level, placing the patient at significant risk for infection.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-10

Question 12

Type: MCMA

During the post-transplantation period, a patient received tacrolimus (Prograf). The nurse would monitor this patient for the development of which adverse effects?

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

Standard Text: Select all that apply.

1. Congestive heart failure

2. Nausea and vomiting

3. Hyperglycemia

4. Hair loss

5. Infection

Correct Answer: 3,5

Rationale 1: Tacrolimus is not associated with the development of congestive heart failure.

Rationale 2: Tacrolimus is not associated with the development of nausea and vomiting.

Rationale 3: Tacrolimus, a macrolide antibody, has the development of hyperglycemia as a potential adverse reaction.

Rationale 4: Tacrolimus is associated with hirsutism, not hair loss.

Rationale 5: Tacrolimus increases risk for infection.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-9

Question 13

Type: MCMA

A patient being conditioned for hematopoietic stem cell transplantation will receive muromonab-CD3 (Orthoclone OKT3). Which medications will the nurse anticipate administering before this medication is given?

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

Standard Text: Select all that apply.

1. Acetaminophen

2. Vitamin C

3. Penicillin

4. Diphenhydramine

5. Glucocorticoids

Correct Answer: 1,4,5

Rationale 1: Acetaminophen is given prophylactically to prevent first-dose effect.

Rationale 2: Vitamin C is not standardly administered before this drug.

Rationale 3: Penicillin is not standardly given before this drug.

Rationale 4: Diphenhydramine is given prophylactically to prevent first-dose effect.

Rationale 5: Glucocorticoids are administered prophylactically to prevent first-dose effect.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-9

Question 14

Type: MCSA

A patient recovering from liver transplant surgery is being instructed on the long-term use of steroid medication. Which education should the nurse provide?

1. Abdominal pain and nausea are side effects and are expected.

2. There are no major side effects associated with this medication.

3. This medication helps prevent organ rejection but you must report any vision changes and bone pain and be tested for diabetes regularly.

4. This medication works for a few months and will be discontinued.

Correct Answer: 3

Rationale 1: Abdominal pain and nausea are not expected side effects of glucocorticoid therapy.

Rationale 2: There are major side effects of steroid medications.

Rationale 3: Steroid therapy is useful for prevention of rejection and is used in rescue therapy for organ rejection; however, long-term use is associated with severe bone disorders, diabetes mellitus, and cataracts. The patient should be instructed to report any vision changes and bone pain and should be tested regularly for the onset of diabetes.

Rationale 4: The patient will most likely be on this medication for a very long time, perhaps for life.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-9

Question 15

Type: MCSA

The nurse is caring for a patient recovering from a kidney transplant. Which information should the nurse provide to this patient?

1. You may have a graft site leak, so do not eat or drink anything until I talk to the surgeon.

2. I am going to slow down your IV fluids to see if that brings your blood pressure down.

3. It is probably going to be necessary to give you some fresh frozen plasma.

4. Hypertension is a common problem after surgery, so I will be giving you the antihypertensive medication your surgeon ordered in case this occurred.

Correct Answer: 4

Rationale 1: There is not enough information to support a graft site leak.

Rationale 2: Reducing IV fluids is not likely to be a sufficient intervention to control hypertension in this patient.

Rationale 3: Administration of fresh frozen plasma, which would expand the patients circulating blood volume, is not indicated.

Rationale 4: Hypertension is a common problem in the kidney transplant patient. This condition can be exacerbated during the postoperative recovery period because of fluid volume imbalances precipitated by the high volume of IV fluids used to maintain a high urine flow. Antihypertensive agents may be ordered preoperatively and postoperatively to maintain the blood pressure within an acceptable range for the patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-11

Question 16

Type: MCMA

The nurse is preparing for oculocephalic reflex testing of a patient who may be brain dead. Which equipment should the nurse gather?

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

Standard Text: Select all that apply.

1. Reflex hammer

2. Cold water

3. Syringe

4. Hydrogen peroxide

5. A tongue blade

Correct Answer: 2,3

Rationale 1: A reflex hammer is not used in the determination of oculocephalic reflex.

Rationale 2: The oculocephalic test requires instillation of cold water into the patients ear.

Rationale 3: The oculocephalic test requires a syringe.

Rationale 4: Hydrogen peroxide is not used to test the oculocephalic reflex.

Rationale 5: A tongue blade is not used to test the oculocephalic reflex.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-3

Question 17

Type: MCMA

Apnea testing is being done on a patient that may be brain dead. During the test the patient develops ventricular tachycardia. What nursing action is indicated?

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

Standard Text: Select all that apply.

1. Reconnect the patient to the ventilator.

2. Draw an immediate arterial blood gas.

3. No action is necessary unless ventricular fibrillation ensues.

4. Allow the patient to die a natural death.

5. Treat the dysrhythmia.

Correct Answer: 1,2,5

Rationale 1: If the patient develops cardiac dysrhythmia during testing, the ventilator should be reestablished.

Rationale 2: If a dysrhythmia develops during testing an immediate arterial blood gas should be drawn.

Rationale 3: Action is necessary.

Rationale 4: Actions besides allowing death to occur are indicated.

Rationale 5: Treatment for this patient should occur just as if brain death was not expected.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-3

Question 18

Type: MCSA

A patient declared brain dead after cardiac surgery has been accepted as a potential donor. The family has given consent for donation. The nurse providing care to this patient would expect directions from which provider?

1. OPO coordinator

2. Surgeon

3. Cardiologist

4. Hospitalist

Correct Answer: 1

Rationale 1: After consent is obtained the care of the donor is transferred to the OPO and the OPO coordinator directs care.

Rationale 2: At this point the surgeon no longer is associated with the patients care.

Rationale 3: At this point the cardiologist is no longer associated with this patients care.

Rationale 4: At this point the hospitalist is not associated with the patients care.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-5

Question 19

Type: MCSA

After several months of testing a patient is placed on the United Network for Organ Sharing (UNOS) waiting list for a kidney transplant. The patient says, How long do you think it will take for me to get a kidney? Which nursing response is indicated?

1. Most people get a kidney within the first 6 months of being on the list.

2. It depends upon how much you are willing to pay for a kidney.

3. It is impossible to predict when your kidney will be available.

4. Some people die waiting for a kidney.

Correct Answer: 3

Rationale 1: Only about 17% of people receive a kidney in the first 6 months of being listed.

Rationale 2: The Uniform Anatomical Gift Act prohibits trafficking in organs for a profit.

Rationale 3: Waiting time is impossible to predict and is related to such variables as body size, blood type, and antibody levels.

Rationale 4: This is a true statement, but is not therapeutic.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-7

Question 20

Type: MCSA

The transplant team works to decrease the number of posttransplant infections due to iatrogenic causes. Which nursing intervention would support this goal?

1. Maintaining strict sterile technique with all invasive procedures

2. Teaching the patient to restrict the number of visitors the patients have after returning home

3. Identifying potential source of infection from patient history

4. Assisting with careful screening of donors

Correct Answer: 1

Rationale 1: Iatrogenic infections are those acquired in the hospital following transplantation. Vigilance regarding hand hygiene and sterile technique for invasive procedures can help reduce these infections.

Rationale 2: If a contagion is brought into the home by visitors it is still considered community acquired.

Rationale 3: Infections can reactivate from a dormant state. The team should look for these potential infections during pretransplant evaluations.

Rationale 4: Infections that occur because the donor organ or tissues were infected are called donor-derived infections.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-8

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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