Nokea
Following procurement of organs from a standard criteria donor (donor younger than 50 years who suffered brain death), within what time period should the heart and lungs be transplanted?
- A. 4-6 hours
- B. 8-12 hours
- C. 24 hours
- D. 36 hours
Correct Answer: A
Rationale: Heart and lungs have a short ischemic tolerance, requiring transplantation within 4-6 hours (A) to ensure viability. Longer periods (B, C, D) risk organ failure.
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The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
- A. Hematuria
- B. Muscle spasms
- C. Dizziness
- D. Nausea
Correct Answer: A
Rationale: Hematuria in a client with pelvic and femur fractures suggests possible urinary tract or bladder injury, requiring immediate reporting.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results that show minimal bacteria
- B. Cloudy, foul-smelling urine output
- C. White blood cell count of 14,000
- D. Temperature of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.
A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
- A. Slow the infusion rate
- B. Make sure the client is well hydrated
- C. Record the intake and output every shift
- D. Tell the client to report ringing in the ears
Correct Answer: B
Rationale: Adequate hydration is critical to prevent cisplatin-induced nephrotoxicity by promoting renal excretion of the drug.
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- A. Reverse the direction of the blood flow
- B. Allow better blood supply to the lungs
- C. Relieve pressure on the ventricles
- D. Prevent the need for further correction
Correct Answer: B
Rationale: The modified Blalock-Taussig procedure creates a shunt to improve pulmonary blood flow in Tetralogy of Fallot, enhancing lung oxygenation.